[House Hearing, 109 Congress]
[From the U.S. Government Printing Office]

                             AWARENESS AND TREATMENT


                                    BEFORE THE

                              SUBCOMMITTEE ON HEALTH

                                      OF THE 

                             COMMITTEE ON ENERGY AND 

                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED NINTH CONGRESS

                                  SECOND SESSION

                                   JUNE 28, 2006

                                 Serial No. 109-120

           Printed for the use of the Committee on Energy and Commerce

Available via the World Wide Web:  http://www.access.gpo.gov/congress/house

30-414                      WASHINGTON : 2006
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                      JOE BARTON, Texas, Chairman
RALPH M. HALL, Texas                      JOHN D. DINGELL, Michigan
MICHAEL BILIRAKIS, Florida                  Ranking Member
  Vice Chairman                           HENRY A. WAXMAN, California
FRED UPTON, Michigan                      EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida                    RICK BOUCHER, Virginia
PAUL E. GILLMOR, Ohio                     EDOLPHUS TOWNS, New York
NATHAN DEAL, Georgia                      FRANK PALLONE, JR., New Jersey
ED WHITFIELD, Kentucky                    SHERROD BROWN, Ohio
CHARLIE NORWOOD, Georgia                  BART GORDON, Tennessee
BARBARA CUBIN, Wyoming                    BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois                    ANNA G. ESHOO, California
HEATHER WILSON, New Mexico                BART STUPAK, Michigan
JOHN B. SHADEGG, Arizona                  ELIOT L. ENGEL, New York
  Vice Chairman                           GENE GREEN, Texas
VITO FOSSELLA, New York                   TED STRICKLAND, Ohio
ROY BLUNT, Missouri                       DIANA DEGETTE, Colorado
STEVE BUYER, Indiana                      LOIS CAPPS, California
GEORGE RADANOVICH, California             MIKE DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire            TOM ALLEN, Maine
JOSEPH R. PITTS, Pennsylvania             JIM DAVIS, Florida
MARY BONO, California                     JAN SCHAKOWSKY, Illinois
GREG WALDEN, Oregon                       HILDA L. SOLIS, California
LEE TERRY, Nebraska                       CHARLES A. GONZALEZ, Texas
MIKE FERGUSON, New Jersey                 JAY INSLEE, Washington
MIKE ROGERS, Michigan                     TAMMY BALDWIN, Wisconsin
C.L. "BUTCH" OTTER, Idaho                 MIKE ROSS, Arkansas                       
SUE MYRICK, North Carolina
TIM MURPHY, Pennsylvania

                    BUD ALBRIGHT, Staff Director
                   DAVID CAVICKE, General Counsel
      REID P. F. STUNTZ, Minority Staff Director and Chief Counsel

                       SUBCOMMITTEE ON HEALTH
                   NATHAN DEAL, Georgia, Chairman
RALPH M. HALL, Texas                      SHERROD BROWN, Ohio
MICHAEL BILIRAKIS, Florida                  Ranking Member
FRED UPTON, Michigan                      HENRY A. WAXMAN, California
PAUL E. GILLMOR, Ohio                     EDOLPHUS TOWNS, New York
CHARLIE NORWOOD, Georgia                  FRANK PALLONE, JR., New Jersey
BARBARA CUBIN, Wyoming                    BART GORDON, Tennessee
JOHN SHIMKUS, Illinois                    BOBBY L. RUSH, Illinois
JOHN B. SHADEGG, Arizona                  ANNA G. ESHOO, California
STEVE BUYER, Indiana                      TED STRICKLAND, Ohio
JOSEPH R. PITTS, Pennsylvania             DIANA DEGETTE, Colorado
MARY BONO, California                     LOIS CAPPS, California
MIKE FERGUSON, New Jersey                 TOM ALLEN, Maine
MIKE ROGERS, Michigan                     JIM DAVIS, Florida
SUE MYRICK, North Carolina                TAMMY BALDWIN, Wisconsin
MICHAEL C. BURGESS, Texas                 JOHN D. DINGELL, Michigan
JOE BARTON, Texas                           (EX OFFICIO)                            


Testimony of:
        Insel, Dr. Thomas, Director, National Institute of Mental 
                Health, National Institutes of Health, U.S. Department 
                of Health and Human Services	                         21
        DePaulo, Dr. Raymond, Director, Department of 
                Psychiatry and Behavioral Sciences, Johns Hopkins 
                University School of Medicine	                         26
        Jamison, Dr. Kay, Author and Founder, UCLA Affective 
                Disorders Clinic	                                 32
        Gooding, Dr. Diane C., Associate Professor of 
                Psychology and Psychiatry, University of Wisconsin	 37
        Martin, Jennifer L., Attorney, Law Offices of Jennifer L. 
                Martin	                                                 64
        Lamphere, Gilbert H., Managing Director, Lamphere 
                Capital Management	                                 67
        Earley, Pete, Writer	                                         71

                                   MYTHS AND 
                           PROMOTING RECOVERY THROUGH
                             AWARENESS AND TREATMENT

                            WEDNESDAY, JUNE 28, 2006

                            HOUSE OF REPRESENTATIVES,
                        COMMITTEE ON ENERGY AND COMMERCE,
                             SUBCOMMITTEE ON HEALTH,
                                                             Washington, DC.

        The subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 2123 if the Rayburn House Office Building, Hon. Nathan 
Deal [Chairman] presiding.
        Members present:  Representatives Deal, Gillmor, Shimkus, 
Shadegg, Pickering, Pitts, Ferguson, Myrick, Burgess, Barton (ex 
officio), Pallone, Rush, Eshoo, Capps, Allen, and Baldwin.
        Also Present:  Representative Murphy.
        Staff Present:  David Rosenfeld, Chief Counsel; Randy Pate, 
Counsel; Ryan Long, Counsel; Brandon Clark, Policy Coordinator; 
Chad Grant, Legislative Clerk; John Ford, Minority Counsel; and 
Alex Gerlach, Minority Staff Assistant.
        MR. DEAL.  The subcommittee will come to order and the 
Chair recognizes himself for an opening statement.  We had 
delayed for just a few minutes because we were having technical 
difficulty with the server that is our Web cast to the offices.  I am 
going to take the prerogative of proceeding with the opening 
statements because my colleagues I am sure will forgive me for not 
having their statements broadcast into everybody's office, but I 
hope they will have it finished by the time we get to our first panel.  
        I am proud to say that today we have two expert panels of 
witnesses appearing on the subject of "Mental Health and Brain 
Disease:  Dispelling Myths and Promoting Recovery Through 
Awareness and Treatment."  I think that after we hear these two 
panels we will have a greater understanding of the issues related to 
the treatment for and recovery from severe mental illness.  
        According to the National Institute of Mental Health, an 
estimated 10.4 percent of American adults suffer from bipolar 
disorder, major depressive disorder, or schizophrenia in any given 
year.  These three diseases are included in the list of eight mental 
disorders that are clarified as serious mental illness, or SMIs.  The 
precise cause of these diseases is not clear.  Scientists know that 
SMIs affect the physical nature of the brain, the structure of the 
brain, and have made progress in linking genetic markers to 
specific mental illnesses.  Like many other serious diseases, 
however, the particular factors that cause SMIs are difficult to 
determine.  It is now accepted that bipolar disorder, major 
depression, and schizophrenia are biologically based diseases like 
diabetes, autism, and a host of other physical ailments.  The 
biological nature of these diseases, however, cannot be separated 
from environmental factors that may trigger symptoms or enhance 
their severity.  For example, a recent study showed that if mothers 
with major depression were treated successfully, their children 
were 11 percent less likely to be diagnosed with depression 
themselves.  Clearly both genetic and environmental factors play a 
role in these disease processes. 
        But many high profile citizens have spoken publicly about 
being diagnosed with these diseases in recent years.  Stigma 
surrounding mental illness diagnosis and treatment persist.  Stigma 
can be more or less severe depending on race, sex, ethnicity, 
socioeconomic background, and age.  Moreover, the social and 
economic ramifications of being labeled mentally ill can be 
considerable and sometimes devastating.  
        While SMIs are serious and complex, people who obtain 
effective treatment can be productive and successful in spite of 
their disease.  Treatments available for bipolar disorder, 
depression, and schizophrenia are not perfect or foolproof 
however.  Some have considerable side effects, and it is often 
difficult for patients to take recommended medications 
consistently.  A combination of medication and counseling tends to 
be most effective.  
        According to a 2002 Department of Health and Human 
Services report, diagnosable mental illness costs the United States 
about $170 billion per year in healthcare expenditures and lost 
productivity.  The costs of untreated mental illness are staggering, 
including homelessness, substance abuse, criminal behavior, 
incarceration, unemployment, and suicide.  Research conducted at 
NIMH indicates that over 90 percent of people who commit 
suicide have depression or other diagnosable mental or substance 
abuse disorder.  
        The first panel today will provide an overview of severe mental 
illnesses.  Dr. Raymond DePaulo will address the burden of mental 
illness in the United States.  Dr. Thomas Insel will discuss current 
research initiatives that demonstrate the biological nature of these 
diseases and the effectiveness of current treatments.  He will also 
provide an outline of the NIMH's mission for future research. 
        Dr. Kay Redfield Jamison will testify as both a person with 
bipolar disorder and as one of the disease's leading experts.  
Dr. Jamison will discuss current trends and treatment of bipolar 
disorder and major depression as well as the risk associated with 
untreated illness.  Dr. Diane Gooding will testify about the 
biological basis of schizophrenia and highlight effective treatment 
        The second panel will discuss their experiences with seeking 
help, diagnosis and treatment.  Jennifer Martin is an attorney who 
was diagnosed with major depression.  Gil Lamphere, Managing 
Director for Lamphere Capital Management, also suffers from 
depression.  Mr. Pete Earley, a local author and former 
Washington Post reporter, has a son who has struggled with 
bipolar disorder for several years.
        Again, I would like to thank all our witnesses for participating 
today.  I would also like to give a special thanks to Ms. Myrick 
from North Carolina, a member of our committee, and her staff, 
whose hard work and dedication to helping those suffering from 
brain disease has made today's hearing possible. 
        At this time I would like to ask unanimous consent that all 
members are allowed to submit statements and questions for the 
        Without objection, it is so ordered.  I am now pleased to 
recognize in the place of our normal Ranking Member a very able 
substitute, Ms. Baldwin, for her opening statement. 
        [The prepared statement of Hon. Nathan Deal follows:] 


	 The Committee will come to order, and the Chair recognizes 
himself for an opening statement.
	 I am proud to say that we have two expert panels of witnesses 
appearing before us this morning that will help us examine 
issues related to the treatment for and recovery from severe 
mental illness.
	 According to the National Institute of Mental Health, an 
estimated 10.4 percent of American adults suffer from bipolar 
disorder, major depressive disorder, or schizophrenia in any 
given year.  These three diseases are included in a list of eight 
mental disorders that are classified as serious mental illnesses, 
or SMI's.
	 The precise cause of these diseases is not clear.  Scientists 
know that SMI's affect the physical structure of the brain and 
have made progress in linking genetic markers to specific 
mental illnesses.  
	 Like many other serious diseases, however, the particular 
factors that cause SMI's are difficult to determine.
	 It is now accepted that bipolar disorder, major depression, 
and schizophrenia are biologically based diseases like diabetes, 
autism, and a host of other physical ailments.  
	 The biological nature of these diseases, however, cannot be 
separated from environmental factors that may trigger 
symptoms or enhance their severity.  For example, a recent 
study showed that if mothers with major depression were 
treated successfully, their children were 11% less likely to be 
diagnosed with depression themselves.  Clearly, both genetic 
and environmental factors play a role in these disease 
	 Though many high profile citizens have spoken publicly about 
being diagnosed with these diseases in recent years, stigma 
surrounding mental illness diagnosis and treatment persists.  
Stigma can be more or less severe depending on race, sex, 
ethnicity, socioeconomic background, and age.  Moreover, the 
social and economic ramifications of being labeled "mentally 
ill" can be considerable and sometimes devastating.  
	 While SMI's are serious and complex, people who obtain 
effective treatment can be productive and successful in spite of 
their disease.  Treatments available for bipolar disorder, 
depression, and schizophrenia are not perfect or foolproof, 
however.  Some have considerable side effects and it is often 
difficult for patients to take recommended medications 
consistently.    A combination of medication and counseling 
tends to be most effective.  
	 According to a 2002 Department of Health and Human 
Services report, diagnosable mental illness costs the United 
States about $170 billion per year in health care expenditures 
and lost productivity.  The costs of untreated mental illness are 
staggering, including homelessness, substance abuse, criminal 
behavior, incarceration, unemployment, and suicide.  Research 
conducted by NIMH indicates that over 90 percent of people 
who commit suicide have depression or another diagnosable 
mental or substance abuse disorder.  
	 The first panel will provide an overview of severe mental 
illnesses.  Dr. J. Raymond DePaulo will address the burden of 
serious mental illnesses in the U.S.  
	 Dr. Thomas Insel will discuss current research initiatives 
that demonstrate the biological nature of these diseases and the 
effectiveness of current treatments.  He will also provide an 
outline of the NIMH's mission for future research.  
	 Dr. Kay Redfield Jamison will testify as both a person with 
bipolar disorder and as one of the disease's leading experts.  
Dr. Jamison will discuss current trends in diagnosis and 
treatment of bipolar disorder and major depression as well as 
the risks associated with untreated illness.
	 Dr. Diane Gooding will testify about the biological basis of 
schizophrenia and highlight effective treatment strategies.  
	 The second panel will discuss their experiences with seeking 
help, diagnosis, and treatment.  Jennifer Martin is an attorney 
who was diagnosed with major depression. 
	 Gil Lamphere, managing director of the Lamphere Capital 
Management, also suffers from depression.  Mr. Pete Earley, a 
local author and former Washington Post reporter, has a son 
who has struggled with bipolar disorder for several years.
	 Again, I would like to thank all of our witnesses for 
participating today, and I would also like to give a special 
thanks to Ms. Myrick from North Carolina and her staff whose 
hard work and dedication to helping those suffering from brain 
disease has made today's hearing possible.
	 At this time, I would also like to ask for Unanimous Consent 
that all Members be allowed to submit statements and 
questions for the record.
	 I now recognize the Ranking Member of the Subcommittee, 
Mr. Brown from Ohio, for five minutes for his opening 

        MS. BALDWIN.  Thank you, Mr. Chairman, and thank you so 
much for holding this very important hearing today. 
        Part of the purpose of this hearing is to raise awareness about 
mental illness and reduce the stigma associated with it, and these 
are certainly worthy goals and I know many of my colleagues join 
me in sharing them. 
        It is amazing to me to think that one of the biggest challenges 
that continues to face mental health researchers, advocates, 
parents, and patients is the belief that mental illness is not a real 
illness, and frankly it is sad that this continues to be a commonly 
held misconception in the year 2006. 
        I consider myself lucky because courageous family members, 
dear friends and constituents have told me their stories and shared 
with me their struggles so that I might understand.  
        The Alliance for the Mentally Ill, or AMI, which in French 
means "friend," was founded in the Congressional district that I 
have the honor of representing.  This advocacy group has made 
amazing strides with regard to public policy change, meanwhile 
providing important public education on mental illness as well as 
support for families dealing with a new diagnosis.  
        I am happy that our first panel of witnesses is here to inform 
and update us on the exciting and groundbreaking work that is 
being done in the arena of mental health research.  Mental illnesses 
are tangible, treatable health problems just like hypertension or 
cancer or heart disease, and I know that the research being done 
confirms this every day. 
        Just as heart disease is a disease of the heart, mental illness is a 
disease of the brain, and the more that we can learn about the 
origins, symptoms and treatment of mental illness, the more 
ammunition we have to fight the myths and stigma that surrounds 
mental illness. 
        While holding this hearing is a promising step, I think that 
there are several other steps that we as Members of Congress can 
take to promote awareness and reduce stigma. 
        One is to support adequate funding for the NIH.  It is 
unacceptable that after a significant commitment that this Congress 
has made to doubling the NIH budget, we have allowed that 
momentum to disappear by flat funding the NIH in recent years.  
In the world of medical research, where the costs of doing research 
are continually rising, this flat funding translates into a cut. 
        In the past few years, funding for qualified grant applications 
has fallen to about 20 percent from a high of about 33 percent at 
the peak of the doubling in 2001, and I wonder sometimes what 
this says to young aspiring researchers.  
        Similarly unacceptable is this Congress' inability to pass 
mental health parity legislation.  Mental illness is no different from 
physical illnesses.  It should be covered by insurance in a 
nondiscriminatory manner.  And we see this inequity in private 
insurance and even in Medicare.  It is time to pass mental health 
        Lastly, I would like to extend a very warm welcome to my 
constituent, Dr. Diane Gooding, Associate Professor of Psychology 
and Psychiatry at the University of Wisconsin, Madison.  
Dr. Gooding, I am honored you were able to join us and I am very 
proud of the groundbreaking research that is conducted at the 
University of Wisconsin Madison, and this holds true for the 
research that you are doing regarding schizophrenia.  Thank you 
for joining us and thank you to the rest of our witnesses as well, 
especially those who are courageously sharing their personal 
stories so that we may learn.  
        Thank you, Mr. Chairman.  
        MR. DEAL.  Thank you.  I am pleased to recognize the 
Chairman of the full committee, Mr. Barton from Texas, for an 
opening statement. 
        CHAIRMAN BARTON. Mr. Chairman, I will submit my statement 
for the record.  I appreciate you doing the hearing and I look 
forward to hearing from our witnesses. 
        [The prepared statement of Hon. Joe Barton follows:] 

	Thank you Chairman Deal for holding this hearing on the 
important topic of mental health, also increasingly referred to as 
brain disease.
	As science advances and as our understanding of the human 
body increases, we are coming to a greater awareness of the 
infinite intricacies of the human brain.  A brain is faster than the 
fastest super computer ever built, performing millions of 
calculations per second and storing enormous quantities of 
information.  Our brains are marvelous tools we rely on every 
second to navigate through a dangerous world.  The brain also 
allows us to ponder and ask questions about the universe and our 
place in it.  
	With all the activities the brain coordinates and makes possible 
for us, we encounter remarkably few problems.    The artificial 
intelligence we now use each day may be wizardry, but it's no 
match for the brain.   Generally speaking, the mind does not 
require rebooting, does not freeze up or shut down just as you get 
ready to save something.  Memories may fade, but they're not 
usually deleted.  
	Sometimes, however, our brains do encounter problems that 
interfere with our functioning as human beings.  When that 
happens, it can be disastrous for the patient, but also for family, 
friends, and colleagues.
	We are learning more every day about how the brain works and 
how to fix it when it breaks, and I want to say a special word of 
thanks to Sue Myrick at this point.  Sue was the driving force 
behind today's hearing.  Her family knows what it is to encounter 
the problems and the stigma of a disease that is just as destructive 
as cancer and disabetes, and I want to applaud her courage and her 
determination to bring these issues into the light.  
	Today we will hear from a distinguished panel of experts about 
the biological and environmental causes of common mental 
illnesses and learn about the exciting research and treatments that 
are becoming available to us.  
	We are also fortunate to have with us today on our second 
panel three people who have experienced mental illness either as a 
patient or as a family member.  They are here to shed light on their 
battles with mental illness as well as on their struggles with its 
unfortunate and unfair stigma; more often the result of ignorance 
than malice.  I look forward to hearing each of their stories today 
and thank them for being here.
	Thank you again Chairman Deal for holding today's hearing 
and welcome to our witnesses.   
        MR. DEAL.  I thank the gentleman.  I would then recognize Ms. 
Myrick, who is really the leader of this cause and brought this 
issue before the subcommittee.  Ms. Myrick.  
        MS. MYRICK.  Mr. Chairman, thank you and I really appreciate 
this opportunity that you are holding the hearing today and I want 
to thank all of you that are here to share with us because you are 
what makes it happen as well.  
        The real goal that I have in mind is, personally today with this 
hearing, is to bring mental illness out of the shadows and 
emphasize it conceptually, these are really brain diseases, 
conditions that are biological, they are diagnosable and they are 
treatable.  And though the title says mental illness and brain 
disease, they are really one and the same.  
        Monday, after an article appeared in my local paper that we 
were going to have this hearing, I was really encouraged because I 
was going through the airport and after I got on the plane a lot of 
people came up to me and just said, thank you, thank you for doing 
this.  And what that said to me was this is a bigger problem than 
anybody is willing to admit.  It really affects a lot of us, and again 
those of you who are sharing your personal stories, thank you, 
thank you, thank you because the more of that that happens, the 
more progress we are going to make.  
        Today we are going to focus on three diagnoses that fall under 
the severe mental illness category: major depression, bipolar 
disease, and schizophrenia.  These are some of the most serious 
mental illnesses, and acknowledging that these diseases exist is 
good for our whole society, not just for parents and patients and 
the people who deal with it.  Awareness provides a clearer path to 
treatment and lessens the personal and societal costs of the disease. 
        You know, all of us on this subcommittee support various 
awareness hearings and programs for diabetes, breast cancer, 
arthritis, chronic pain, Alzheimer's, everything else.  This is just 
another one that we need to consider in the same way.  
        You know, I think about what it was like 20 to 30 years ago 
when nobody wanted to say I have cancer.  You know it was a 
stigma that you just never told anybody.  You were afraid to go 
forward because you might lose your job or women would say to 
me, you know, I might--my husband will leave me.  Whatever the 
reason, nobody would talk about it. 
        And when I went public with my breast cancer in 2000, a lot of 
close friends and colleagues came up to me and said, I have had 
breast cancer.  I had known them 20 years and they never told me.  
They kept it a secret.  And it is really I believe the same thing that 
we are dealing with today with brain disease.  We are in the same 
position.  People don't want to talk about it because they are afraid.  
Sometimes they think there is no solution to the problem.  But 
there are ways to live with it, and I hope that will be clear today. 
        We have a granddaughter who is bipolar, and she first started 
suffering with this when she was about 13 years old.  It has been a 
long road.  She is now an adult and, very frankly, the whole family 
has lived this story the whole time.  And it doesn't affect just the 
person.  It affects the family.  And that is I think the thing that we 
forget about.  Everybody gets involved.  It is not just the patient.  
And so, we as a family have spent countless hours, counseling and 
trying to get her to accept treatment that you know she will accept, 
worrying about her.  Those of you who have been through it know 
what it is like.  But they are life threatening diseases and we don't 
realize that. 
        In 2001, by the way, more Americans killed themselves 
through suicide, which is directly related to these diseases in many, 
many ways, than died of HIV and AIDS.  And when I saw that, 
that really hit me hard because we don't consider that the same 
        So we need to get to the root of the problem, why are people 
committing suicide?  It is because there is another problem there 
that they are dealing with that hasn't been dealt with themselves.  
And so the progress in research to me is so great.  I mean there is 
no reason for hopelessness with this issue because those of you in 
front of us have been doing wonderful work.  Other people are 
doing wonderful work.  And we are finding out more and more 
that there are solutions to the problem, that we really can be 
hopeful about what can happen.  
        So I really welcome all of you again.  Thank you from the 
bottom of my heart for what you do every day, and for those of 
who you who are sharing with us, thanks again for being here. 
        MR. DEAL.  I thank the gentlelady.  Mr. Pallone is recognized 
for an opening statement. 
        MR. PALLONE.  Thank you, Mr. Chairman.  I am glad we are 
holding today's hearing.  Now more than ever we need to be 
talking about mental health.  Nearly 30 million Americans suffer 
from mental health disorders and more than one in five persons 
will experience a mental health disorder in their lifetime.  Millions 
of people suffer from serious, debilitating and life altering mental 
illnesses, such as bipolar disorder and schizophrenia, and nearly 
every American has a friend or relative that has to cope with such 
        Mr. Chairman, I have to be honest, while I appreciate your 
calling today's hearing, the truth of the matter is that for far too 
long the Republican led Congress has shirked its responsibility 
when it comes to mental health in America.  One hearing on 
mental health cannot make up for the many years this important 
topic has been largely ignored or for the harmful policies that my 
Republican friends have enacted over the past few years by cutting 
Federal programs that could provide some help.  And I recognize 
the importance of raising public awareness, but I don't know how 
you can talk about treatment and recovery without talking about 
access, which I think increasingly is a problem. 
        Many of the witnesses testifying today will talk about new 
research and breakthrough discoveries, yet what good is it if the 
research never reaches the patient?  Millions of Americans are 
unable to access life-saving treatment and therapy because this 
committee, and I think the Republican leadership, have not taken 
action on the Paul Wellstone Mental Health Parity Act, which my 
colleague from Wisconsin mentioned has strong support from both 
sides of the aisle, including many members of this committee.  So 
we should simply move it. 
        And I think the Republican record on mental health issues or 
the problem with the lack of record doesn't stop there.  It is one 
thing to block important legislation such as the Parity Act that 
would undoubtedly improve access to mental health services, but it 
is another thing to pass legislation that would further restrict 
treatment options, which is exactly what Republicans did when 
they gutted Medicaid this year.  
        Medicaid, as we know, is the single largest source of funding 
for mental health care in this country, comprising over half the 
State and local spending on mental health services.  But that didn't 
stop this Congress, again the Republican leadership, from taking 
their red pen during last year's reconciliation and slashing billions 
from the Medicaid program.  As a result millions of low-income 
people who suffer from debilitating mental disorders, some of our 
most vulnerable citizens, will have to overcome new barriers to 
care such as prohibitive cost sharing requirements for medications, 
and I have no doubt that their mental health is now in jeopardy.  
        Again I want to thank the Chairman for holding today's 
hearing.  Certainly, raising awareness about mental health and 
treatment is an important topic, but so is access.  And if my 
Republican friends are truly interested in improving the current 
state of mental health in this country then a good first step would 
be addressing the lack of access that most Americans face or many 
Americans face when they seek treatment.  
        Thank you, Mr. Chairman.
        MR. DEAL.  I now recognize Mr. Ferguson for an opening 
        MR. FERGUSON.  Thank you, Mr. Chairman.  I don't have a 
prepared opening statement, but I want to thank you for holding 
this hearing.  I want to thank Sue Myrick for her leadership on this 
issue, and I am pleased to be able to be here to listen to our 
witnesses today and to read their testimony because this is a very 
difficult and very important issue.  There are so many 
misunderstandings and a lack of awareness that Ms. Myrick 
touched on before that surround mental illness and brain disease.  
People don't talk about it very much and Ms. Myrick was referring 
to that earlier.  And even though people don't talk about it a lot, 
and there is this still unfortunately this stigma that surrounds 
mental illness, many, many, many families are touched by mental 
illness and brain disease and frankly my family is one of them. 
        Mental illness and brain disease are particularly difficult to 
deal with because they are not immediately physically apparent to 
others, and it is only through real process of diagnosis and 
investigation do they become better known or more apparent.  And 
because of that, it makes it extremely difficult on a family, on the 
loved ones of the person who is affected, and it makes it even more 
difficult, frankly, to translate that into more public awareness and 
frankly good public policy.  
        I have been a supporter of the mental health parity efforts here 
in the Congress.  I have a very, very close friend at home who is a 
young person who is struggling with brain cancer right now, that 
the brain is so difficult and so complex and it is my hope that 
through Sue Myrick's efforts, this committee's efforts, this 
Congress' efforts that we will begin to know more and more about 
the brain and about how we can conquer the difficulties and the 
challenges that we face in treating brain disease and mental illness.  
        You know, 20 and 30 years ago, people in the healthcare field 
talked about the heart and they talked about cancer, and we have 
made such incredible progress when it comes to the heart and to 
cancers and other previously really vexing diseases and difficulties 
and afflictions that human beings deal with.  It is really my hope 
and belief that this next frontier, the next huge breakthroughs in 
human health are going to come with the brain and it is my hope 
that through hearings like this, Mr. Chairman, and the efforts of 
this Congress that we can continue to further those efforts. 
        So thank you very much again for holding this hearing, Mr. 
Chairman.  I appreciate your leadership on this issue and I yield 
        MR. DEAL.  I thank the gentleman.  Ms. Eshoo is recognized 
for an opening statement.  
        MS. ESHOO.  Thank you, Mr. Chairman, for holding this 
hearing and I want to salute our colleague, Congresswoman 
Myrick, for being the agitator as it were to make sure that we have 
this examination.  It is an important hearing for all the reasons that 
my colleagues have stated. 
        All we have to do, as many of my colleagues have said, is just 
look within our own circle, our families and our close friends, to 
know that this is something that is really relatively common, and 
that much progress has been made in terms of research and the 
examination of the human brain. 
        I think that in one of the individual's testimony they used the 
following phrase, that this is the treatment of cancer in the 21st 
Century--I am just paraphrasing.  It wasn't all that many years ago 
when the word "cancer" was like an atomic bomb when the word 
was stated.  There was hopelessness that accompanied the word, 
and now the progress that has been made--well we could go on and 
on, we could have hearings celebrating the progress.  There is a 
reason for that, and I think that our committee needs to 
reappreciate it.  And that is that we made it a top priority in the 
country.  And when we did, we said that we would invest in the 
necessary research in order to advance cures for the disease. 
        Now there are some cancers we haven't conquered yet.  There 
are others that are really stoppable and curable.  As we did that, we 
also recognized that if anyone that was afflicted with cancer did 
not have access to what the researchers had brought forward, then 
they were condemned to essentially the past.  In other words, they 
might as well be living without the benefit of the research.  And so 
today is one of the steps, in my view, along the way because there 
is much to do.  
        We know that there are several of our colleagues battling this 
illness, and one of our colleagues talked about this today.  Patrick 
Kennedy has been very courageous in coming out and talking 
about his illness.  We know that a President of the United States--
at least one, maybe there were many--Abraham Lincoln suffered 
from what I think was what we would now call depression for 
different bouts in his life and spent time I think with family or 
friends because he needed them not only to help him, but also 
probably so that he wouldn't harm himself. 
        So the history is very rich in terms of experience.  
        We need to not only hear from the researchers today and those 
that have firsthand experience, but I hope what the subcommittee 
will do is to take the next step, and that is to see that we have 
robust funding for the research, because the breakthroughs will not 
be made and we will really all be condemned to the discrimination 
and the lack of awareness of the past unless we make the proper 
investments.  And then the step that comes with that is that there 
not be a discriminatory system in terms of access to what the 
researchers put out there for all Americans.  And when we do that, 
we will give hope to humankind because the United States of 
America is always first.  Always first.  We have a great pride in 
that and it is justifiable.  But it won't happen unless the political 
will is really exhibited. 
        It wasn't that many years ago when Richard Burr was on this 
committee, we had legislation that established the National 
Institute of Bioimaging and Bioengineering.  That was all it was.  
We did that because we understood that through the bioimaging 
and through the bioengineering that breakthroughs could indeed be 
made, but only unless and until we made that investment, which 
we did.  We were very proud of the work that we did.  President 
Bush signed that bill into law. 
        These are all steps in the right direction.  The President has 
said, I believe it was in 2002, that he favored ending 
discriminatory insurance coverage.  And so we should not only be 
comforted by that, but match his forward thinking on this.  It will 
take some boldness because there seems to be an attitude around 
the Congress that we could take some baby steps, but we can't take 
the last full step that will need to be taken. 
        And this is a bipartisan issue.  It is a nonpartisan issue.  And 
there are many, many Americans, too many Americans that are 
still waiting in the wings to have this addressed.  
        So thank you, Mr. Chairman, thank you to our colleague, 
Congresswoman Myrick, and to the researchers, the leaders that 
are here as well as those that are going to give testimony, which I 
think is very courageous, from their own experience.  I look 
forward to hearing from you. 
        MR. DEAL.  Thank you.  Mr. Shimkus is recognized for an 
opening statement. 
        MR. SHIMKUS.  I will yield, Mr. Chairman.
        MR. DEAL.  Mr. Shadegg is recognized for an opening 
        MR. SHADEGG.  Thank you, Mr. Chairman.  I will make a few 
brief remarks.  I want to commend you for holding this hearing.  I 
want to commend my colleague, Ms. Myrick, for drawing our 
attention to this topic.  It is a topic that affects all of us.  
        I remember as a young child in Phoenix, Arizona, growing up 
both seeing homeless people on the streets and at times going past 
the Arizona State asylum for mentally ill and thinking about this 
        Obviously it is an issue that concerns us as a society.  We as a 
Nation I think long ago made a decision that no American should 
go without basic healthcare, and for that reason we passed various 
laws that ensured that Americans can go, for example, to an 
emergency room, and get health care.  Many of us, as you know, 
Mr. Chairman, are working on legislation that will even improve 
upon that system and would provide better coverage for the 44 
million or more uninsured Americans who for one reason or 
another, largely for many of them it is cost, can't today get health 
insurance or afford health insurance.  A part of that big puzzle is 
the mentally ill.  
        I worry today with the deinstitutionalization of many mentally 
ill which occurred in decades gone by, there are too many 
homeless that are affected by mental illness and we are not caring 
for them enough.  I know it is an issue about which we need to be 
concerned and I commend you for holding the hearing.  
        The specific topic of this discussion today is treatment for and 
recovery from severe mental illness.  That is very important.  
Obviously, a family member can affect the entire family when they 
have these kinds of diseases and we need to touch upon them.  
        In the discussion, however, I would hope that we would look at 
the issue of balance.  One of my concerns is that mandated health 
care coverage runs up the cost of health insurance for everyone, 
and I am deeply worried about America's overall competitiveness 
in the world, in the business realm because of the cost of health 
insurance today.  
        The President of Intel visited me just toward the end of last 
week in my office and his major concern for their competitiveness 
worldwide is that the cost of health insurance is going to make 
America uncompetitive in the market which means that the market 
for building those products will move overseas and America will 
lose jobs to countries where the cost of health insurance isn't so 
        It could well be that rather than directing additional resources 
to come out of the insured population maybe these are insurance 
where the taxpayers themselves through the National Institutes of 
Health or other government organizations should be looking at 
funding these costs because of the incredible burden that cost of 
healthcare can impose on America's economy in a worldwide, very 
competitive economy, where we have to compete with all the 
countries around the world.  That is an aspect we need to look at.  
        With that, Mr. Chairman, I yield back. 
        MR. DEAL.  I thank the gentleman.  Ms. Capps is recognized 
for an opening statement. 
        MS. CAPPS.  Thank you, Mr. Chairman, and I too thank you for 
holding this hearing.  I salute our colleague, Sue Myrick, for 
pulling together an expert panel of witnesses and making this day 
happen in the life of our subcommittee and I would be one who 
would be in favor of this not being an occasional time to raise 
awareness for us.  We need that, but we surely could use the 
community's NAMI, National Alliance of Mental Illness, and 
mental health associations, that we have those groups in our 
communities to help us along with our expert witnesses to set some 
benchmarks for ourselves in terms of achievable standards and 
goals that we really have a responsibility to meet and make this 
day worth something. 
        It is important in itself because it gives us a chance to discuss 
issues that are significant, that are life saving, that will have a 
positive effect on our economy, that we just need to be doing as a 
civilized nation in this world today. 
        I came to Washington as a spouse in the late 1990s, and 
because of that position I was able to avail myself of the last 
couple of years of the decade of the brain and to learn about the 
breakthroughs and the radical transformations in understanding the 
brain and the illnesses and disease conditions that can be affected 
by imaging technology, and the National Institute of Mental Health 
has really pushed us and opened so many doors for our society that 
are now just poised to becoming standards of practice.  Again it is 
all about who has access to care, in my opinion. 
        But I was privileged also to be here in the beginning of my 
term in Congress when the White House had its first ever, I 
believe, conference on mental illness and, Dr. Jamison, that is 
when I first heard you and I was struck by many of you--all of you 
may have there.  I don't know--but the power of people telling 
their stories. 
        And what a long way that goes and some of the outgrowth 
from that conference and other effects on destigmatizing and the 
multimedia campaign to raise awareness among our young people 
in language they could understand and can understand.  We have to 
keep that momentum going because we have a dual purpose, I 
believe, to keep the awareness level but also to make sure that we 
see mental health and diseases of the brain as parity, as a part of 
health every bit as much as a broken arm or a leg or a situation 
requiring insulin if you have diabetes.  
        We have come a long way with cancer.  We need to do the 
same thing in this situation, and yet today in 2006 I know because 
my brother who lives with bipolar disorder has taught me so much 
throughout his adult life on what this means.  We still carry 
stigmas and we still leave so many people without access to 
treatment that could make such a difference in their lives. 
        So we have our work cut out for us, and one of the areas that is 
so significant to me is the determination by many of our insurance 
carriers that therapy and comprehensive treatments are not worth 
the bottom line and that we can only do short term, we can only do 
capped treatments, we can only do quick fixes.  And that means we 
haven't learned what we need to know about the short-sightedness 
of some of this.  
        Now we need to know that.  We do know that mental illness 
needs to be treated like other illnesses.  Many of you know I was a 
school nurse for 20 years.  And if a student were to come to my 
office with a broken arm, what if I just gave that person a 
Band-Aid and sent them back to class?  I mean, it is appalling to 
think of that, and that is what we are doing with people who 
present themselves to those who are professionals and, you know, 
X-rays and treatment, but denying patient coverage to 
psychotherapy by telling them that their mental health 
professionals' recommended course of treatment is unnecessary 
and forcing those individuals to cope alone is exactly like putting a 
child with a broken limb back into the classroom with a pat on the 
back and a Band-Aid.  
        So we cannot afford to let this go on.  We have the ability to set 
standards.  We have shirked our responsibilities, and that is why 
this day and this opportunity that we have with these witnesses 
here is important.  We need to be listening to what you are going to 
be telling us that we need now in this society and this century to 
take mental illness more seriously and to bring the issue of parity 
to the floor.  
I yield back. 
        MR. DEAL.  Mr. Pitts is recognized for an opening statement. 
        Dr. Burgess is recognized for an opening statement. 
        MR. BURGESS.  Thank you, Mr. Chairman.  Actually in the 
interest of time I submit for the record and look forward to hearing 
from our witnesses. 
        [The prepared statement of Hon. Michael C. Burgess follows:] 


        I would like to thank Chairman Deal for holding this hearing 
on mental health and brain disease.  
According to the National Institute of Mental Health (NIMH), 
6 percent of Americans ages 18 and older or 1 in 17 adults suffer 
from a serious mental illness.  Individuals can also be diagnosed 
with several disorders at one time.  
        During this hearing, we will focus on the following illnesses - 
major depressive disorder, bipolar disorder, and schizophrenia.  
Major depressive disorder and bipolar disorder are mood 
disorders.  In addition, major depressive disorder is the leading 
cause of disability in the United States for people between the ages 
of 15 to 44.  Next, schizophrenia affects about 2.4 million 
American adults.  Both men and women have an equal chance of 
developing schizophrenia.  In consequence, the lives of millions of 
Americans are touched by these diseases.  
        Mental illnesses can be devastating to the affected person as 
well as his family.  As with every disease, people can become 
affected by a mental illness at any time in their lives.  These can be 
difficult to diagnose and much research is still needed to bring us a 
better understanding of the biological basis for these brain 
diseases.  The brain can now be studied in greater depth, as our 
technology improves, such as with functional MRI that can tract 
the blood flow associated with different brain activities.  
Furthermore, studies on the signaling molecules, such as 
neurotransmitters, are leading to discoveries about where they are 
located and what they are involved with.  Many of these mental 
disorders have already been associated with disruptions in normal 
brain processes.  This knowledge about pathways is crucial to 
develop more targeted drugs.  
        Making a proper diagnosis can be difficult, but it is just the 
initial step.  The treatment that works best for an individual can 
sometimes remain elusive.  However, once it is found, these 
individuals have a chance to lead fulfilling lives if they continue 
their treatments throughout their lifetimes.  Two issues that 
physicians consider are compliance and the medication side 
effects, which are both important factors in the successfulness of 
        I look forward to the testimony from the first panel on the 
ongoing research and the direction it is headed.  Our discussion 
would also not be complete without getting the perspective of 
patients and their daily lives with these mental illnesses.  The 
second panel will bring us some of these insights.  Thank you for 
being here with us today.

        MR. DEAL.  Mr. Allen is recognized for an opening statement.
        MR. ALLEN.  Thank you, Mr. Chairman, for convening this 
hearing to examine the progress our Nation has made in identifying 
and treating mental illness and brain disease.  Mental illness can 
have a devastating impact on Americans from all walks of life.  
One in five Americans is affected by mental illness. 
This hearing can help raise awareness, ease the stigma of 
mental illness, and let patients and their families know there is 
hope.  Since 1996, Congress has been working to pass bipartisan 
legislation to ensure that Americans have access to affordable 
mental health care. 
        Though it is not the focus of this hearing, I want to point out 
that H.R. 1402, the Paul Wellstone Mental Health Equitable 
Treatment Act of 2005, has 227 cosponsors.  I hope that our 
committee will hold a hearing on that bill later this year. 
        Lack of access to mental health treatment as a result of 
insurance discrimination costs our economy more than $100 billion 
each year through absenteeism, turnover and retraining expenses, 
lower productivity, and increased medical costs. 
        There is no scientific or medical basis that justifies insurance 
coverage of mental health disorders on different terms and 
conditions than other coverage for other illnesses or disorders.  The 
State of Maine has been a leader in this area by requiring that 
insurers provide the same level of coverage for mental health care 
as for other illnesses. 
        We also need to invest more funding in medical research to 
diagnose, treat, and find cures.  Of great concern to me is the lack 
of mental health professionals, particularly in rural areas, and 
especially those who treat children with mental illnesses, a major 
problem in my home State of Maine.  
        I look forward to hearing our distinguished panel share their 
experience and expertise.  Together we need to find ways to build 
a comprehensive, efficient system to identify, evaluate, diagnose, 
and treat mental illnesses at every stage of life and ensure that all 
Americans have access to mental health services.  
        With that, Mr. Chairman, I yield back. 
        MR. DEAL.  I thank the gentleman.  The bell, as you heard, we 
have a motion to adjourn on the floor which we will need to go 
vote on.  But before that, I am going to ask unanimous consent of 
the subcommittee that one of the members of our full committee be 
allowed to make an opening statement.  He is a licensed clinical 
child psychologist and that is Mr. Murphy. 
        Without objection, Mr. Murphy will be recognized for 
3 minutes to make an opening statement, and then we will go vote 
and return. 
        MR. MURPHY.  I thank the Chairman for this opportunity.  We 
heard over and over again mental illness is a real and not imagined 
problem, as real and devastating to a family as any other medical 
illness.  It can lead you to lose a job.  It can lead you to lose your 
family and cost business productivity.  In fact it can cost 
employees billions and it does cost lives. 
        And yet, it is more treatable than many other medical 
diagnoses.  If we ignore it, mental illness can both increase the risk 
of heart disease and if mental illness is untreated it can double the 
cost of healthcare.  Without integrating the care of the body with 
the care of the brain, our current system is wasting billions of 
        But the private sector has time and time again demonstrated 
that direct healthcare cost savings can save money as well as 
productivity.  One study reported that when depression 
management was included in their health plans productivity 
increased over 6 percent and absenteeism declined 28 percent with 
a savings of over $2,000 per employee.
        When workers with depression receive treatment, medical costs 
declined by over $800 per employee.  But untreated mental illness 
costs about $300 billion, according to the National Institute of 
Mental Health.  It is $150 billion from lost workdays and 
premature death, $70 billion in emergency care and $80 billion 
from societal costs such as the justice system.  The success in 
treatment requires proper and timely treatment and treatment is not 
just a matter of medication. 
        For example, there was a past concern with use of one 
antidepressant medication associated with increased adolescent 
suicide risk, and it shows you how partial treatment and 
misunderstanding of mental illness actually cause harm.  
Antidepressant medications change mood but they don't change 
your mind.  Psychotherapy performed by a qualified practitioner is 
also needed to properly treat patients.  But when only 25 percent of 
antidepressive medications are prescribed by a psychiatrist and 
75 percent of the time by a nonpsychiatrist and many cases people 
do not receive the additional psychotherapy treatment, then the 
prognosis remains low.  So when health plans do not cover mental 
health treatments, including Medicare, the diseases of mental 
illness cannot be treated properly.  
        Now I urge us to also look at those businesses who have found 
great success in providing this care.  AT&T, American Airlines, 
IBM, and PepsiCo are among those companies who have found 
that good mental health care is good for employees and good 
economics for the business.  The time has come for us to improve 
mental health care by integrating and coordinating medical and 
mental health services for more effective diagnosis and treatment 
rather than just shifting the burden to pay for healthcare or just 
calling for more money.  Congress can lead the way to save lives 
and money through integrated care. 
        I look forward to working with my colleagues to transform our 
health care system, to spend dollars wisely, rather than just spend 
        And I yield back, and I thank the Chairman. 
        MR. DEAL.  Thank the gentleman.  Mr. Gillmor, I believe you 
indicated you would waive your opening statement.  I believe all 
members who are here have given their opening statements.  So we 
will stand in recess pending the completion of the vote.  At that 
time we will resume with our first panel.  Committee will stand in 


        MR. DEAL.  I am pleased to introduce the members of our first 
        Dr. Thomas Insel, he is the Director of the National Institute of 
Mental Health where he has served in that capacity since 2002; 
Dr. J. Raymond DePaulo, recognized as one of the world's 
foremost investigators into the genetic basis of affective disorders 
such as manic depression, depression, and panic disorder; Dr. Kay 
Redfield Jamison, author and founder of the UCLA Affective 
Disorders Clinic.  Dr. Jamison struggled with bipolar disorder 
during her teenage years, successfully completed her Ph.D., and is 
now a professor of psychiatry at Johns Hopkins School of 
Medicine and Co-Director of the Johns Hopkins Mood Disorders 
Center; Dr. Diane Gooding, Associate Professor at the University 
of Wisconsin at Madison, and her research focuses on 
schizophrenia and schizophrenia spectrum disorders as well as 
early detection and prevention measures for mental illness.  
        We are pleased to have all of you here, and we will start with 
Dr. Insel.  
        Your written testimony is made a part of the record.  It will be 
available for Members to read.  We would ask if you would 
summarize during your 5 minutes allotted for your testimony.   

        DR. INSEL.  Thank you, Chairman Deal and Ranking Member 
Baldwin, and thanks especially to Congresswoman Myrick for 
pulling us all together.  I think your leadership here is very 
important to everybody.  
        I will keep my remarks relatively brief given the time.  I am 
Dr. Tom Insel, Director of the National Institute of Mental Health, 
a component of the NIH of the Department of Health and Human 
Services that is tasked with the responsibility of developing 
improved methods of diagnosing, treating, and preventing mental 
disorders, including schizophrenia, autism, and mood and anxiety 
        I am delighted to have an opportunity to be here today.  As you 
mentioned, my testimony has been submitted for the record, so let 
me share with you a few thoughts.  
        I spent yesterday afternoon at a memorial service for a 
23-year-old young man with schizophrenia who killed himself in 
our hospital.  This was a truly tragic event for a young man with a 
tremendous amount of promise.  He was from Tucson, Arizona, 
and as many other people have done who come from all over the 
United States, he came to the NIH Clinical Center to get what is 
arguably the best care available in the United States.  
        This was a fellow who was a creative, tremendously 
compassionate young man who had struggled with schizophrenia 
since about the age of 19 and had been in and out of various 
treatment programs.  When he finally came to us, it was with the 
hope that he would be able to reach a satisfactory stage of 
recovery--everybody was hoping for that.  
        He spent 6 months in our hospital with intensive treatment, 
including a whole range of experimental and available 
medications.  And 2 days before his discharge, he jumped to his 
death.  This was, as Ms. Myrick mentioned before, an event that is 
sort of like dropping a pebble into a pond because it affects so 
many people, not just his family.  Whenever there is a suicide, 
there are many, many victims.  And in this case, it has been a huge 
event for the NIH community, particularly for those who worked 
with this fellow and the people who cared for him.  
        At the memorial service yesterday, what I began to think about 
was how important it was for us to recognize that, at a time like 
this, when we have had such a focus on the need for providing 
better access and providing better services and making sure that 
young people have the best treatments that are available, we also 
need to recognize that for this young man getting the best 
treatment at the best place, we still had the worst outcome.  
        What that says to me is, we are really not where we need to be 
yet.  We need to do much more to be able to make sure that we 
have better treatments for the people who suffer with these very, 
very serious diseases.  
        So I come here really with a very heavy heart as someone who 
is responsible for being able to deliver those treatments in order to 
make life much better and ensure recovery for those with serious 
mental illness.  
        In all fairness, however, I need to tell you that I also come here 
with a lot of hope because I believe in the same heart that we have 
now the opportunities that we have never had before.  
        You heard from your colleagues this morning that there is an 
increasing recognition in the decade following the Decade of the 
Brain that these are brain disorders, that mental disorders are brain 
disorders, a simple and profound truth that has completely altered 
the way that we approach diagnosis and ultimately will alter the 
way we treat them.  
        We recognize that these are chronic disorders.  But unlike 
many other chronic disorders in medicine, these are the chronic 
disorders of young people: 50 percent start by age 14; 75 percent 
by age 24.  This is very different from Alzheimer's disease, 
Parkinson's disease and other neurological brain disorders that we 
think about.  The other difference is that these are brain disorders, 
but they are not brain disorders where a focal lesion can be 
identified.  These are disorders of brain systems.  
        The good news is that we now have the tools to be able to 
understand how brain systems go from being normal to abnormal.  
We have the tools of genomics which give us some of the 
molecular candidates that we need, and we have the tools of brain 
imaging that allow us to look inside the brain.  It is no longer a 
black box, and we can begin to understand where something has 
gone wrong in those that suffer with these disorders.  Finally, the 
last thing that I would like to say to you, besides the fact that these 
are chronic diseases and clearly brain disorders, is that we now 
have the ability to study them.  
        I have submitted for the record a lot more information to back 
up those statements, including a set of pictures that I hope you will 
take a look at that show where some of those abnormal circuits 
appear to be.  I will leave those with you.  I will not go through the 
        But I do want to suggest that we also have a real need to 
change the way we think about these illnesses.  If you can go to the 
second to last slide, what I would like to suggest is where we want 
to go as we think about this and the future and why I have such 
great hopefulness.  We need to go from the point where we are 
now, where we diagnose by symptoms and treat by episode, the 
way we were with heart disease and cancer 30 years ago, to the 
point of understanding the underlying pathophysiology, that is, the 
biological mechanisms, of these illnesses, the way we do now for 
cancer.  That will give us, as indicated on the next slide, both the 
biodiagnostics, biomarkers, and the treatments that really do go 
after the core pathology.  
        The goal here is personalized care, just as it is for cancer.  And 
what I would like to suggest is that we can actually for the first 
time envision what prevention would be like if it is strategic and 
what we call cure therapeutics.  
        The bottom line is that the hopefulness comes from having the 
tools to be able to do that.  We have those tools, and we have been 
using them in a very effective way for other brain disorders.  We 
have been using them for cancer and heart disease.  We can do 
this.  That will be happening over the next 5 years.  
        Finally, we need to find ways to translate those discoveries to 
practice, and that is going to be one of the great challenges we will 
face, even when we get the new tools that we currently use.  We 
will have new discoveries, and that will make a major difference.  
        I want to thank you again for having us to this subcommittee 
hearing.  I think that your leadership in this area will be 
extraordinarily important for those millions of people who suffer 
with these brain disorders.  For me, the bottom line is that through 
research we do have the opportunity to envision this moment of 
hope and we have opportunities that we have never had before in 
thinking about how to approach these illnesses.  Thank you. 
        [The prepared statement of Dr. Thomas Insel follows:]

	Chairman Deal, Ranking Member Brown, Mrs. Myrick and 
members of the Subcommittee:  I am Thomas R. Insel, M.D., 
Director of the National Institute of Mental Health (NIMH), the 
component of the National Institutes of Health (NIH) of the 
Department of Health and Human Service (HHS) tasked with 
responsibility for developing improved methods of diagnosing, 
treating, and preventing mental disorders, including schizophrenia, 
autism, and mood and anxiety disorders.  Thank you for giving us 
this opportunity to share our excitement about progress in 
understanding mental illnesses.   
	Mental illnesses are brain disorders, with specific symptoms 
rooted in abnormal patterns of brain activity; like other medical 
disorders, they are diagnosable, and they are treatable.  This is 
critical, given the tremendous burden mental illnesses exert 
personally, socially and economically.  Unlike most chronic 
medical disorders, mental disorders most often begin in 
adolescence and young adulthood. Without proper treatment they 
can devastate individuals and their families.  Despite this dour 
background, there has been significant advancement in the science 
of mental illness. We have reliable diagnostic tools and effective 
medications and psychological therapies for depression and 
anxiety disorders; we have treatments that can predictably reduce 
the hallucinations and delusions of schizophrenia, as well as 
psychosocial interventions that enable people with disorder to 
remain in their communities, to work and lead productive lives. 	
	We referred to the 1990s as the "Decade of the Brain," based 
on a Congressional Resolution signed by President George H.W. 
Bush on July 17, 1990.   It was a period of major growth in 
neuroscience, revolutionizing the way we think about the brain.  
We were able to demonstrate that mind and body cannot be 
separated, that mental activity can be represented as brain activity, 
and that a clear distinction cannot be made between mental events 
and neural events. One implication of this revolution is the 
recognition of mental disorders as brain disorders.
	For example, studies of children who have the onset of a rare 
form of schizophrenia before age 14 show a marked change in 
brain structure.  When they were initially seen in the clinic in the 
NIMH intramural program at about age eight or nine, they had 
already shown some thinning of the part of the brain called the 
cerebral cortex, compared to the cortical thickness of other eight- 
and nine-year-olds.  Scans of their brains over the next five years 
demonstrated a profound loss of cerebral cortex relative to the 
brain scans of normal children of the same age.  This provided 
strong evidence that childhood-onset schizophrenia involves loss 
of brain matter in a manner similar to other neurological or 
neurodegenerative disorders.  The difference is that in most 
neurological disorders, such as Parkinson's disease, there is a 
specific site of damage.  But, schizophrenia, bipolar disorder, 
depression and autism seem to be disorders of networks, or 
circuits, rather than of specific cells identifiable by brain scan.  

Genes and Neuroscience 
	Since mental disorders are brain disorders, we have been 
exploiting the power of genomics and neuroscience to solve the 
mysteries of the mind. The Human Genome Project in 2003 
provided a full map of the 23,000 genes common to all humans.   
The next vital map, which has just become available in the past 
few months, comes from the International HapMap Project, whose 
goal is to chart all of the common points of variation in the human 
genome.  This new map of variation should give us the clues for 
understanding how one person is susceptible to a mental disorder 
and another is resilient. Genetics and neuroscience together give us 
the tools for predicting risk, validating diagnosis, and identifying 
targets for new, more effective treatments.

Gene-Environment Interactions
	We have learned that genes confer susceptibility; but 
environmental factors, such as the loss of a loved one, traumatic 
events, or physical attributes of the fetal environment, also exert a 
powerful influence on the development of mental illness.  The 
complexity of this interaction is apparent in a serotonin gene that 
has been associated with depression.   A particular segment of the 
gene comes in two forms; people with the "short" form are about 
two to three times more likely to get depressed when also faced 
with severe life stressors, such as death of a family member or loss 
of a job.  Conversely, if a person has the other "long" form, they 
appear to be protected, even when faced with four or more severe 
life stressors. With the protective form, a person is actually no 
more likely to develop depression than if he had experienced none 
of those events.  
	Researchers are now asking how environmental factors during 
critical phases of development exert long-term effects on how and 
when genes are activated. Exploring how genes interact with the 
environment to result in a mental disorder such as depression is not 
much different from understanding how environmental toxins 
contribute to illness. However for mental disorders, the trigger may 
be stressful experiences, the exposure may only have an impact at 
specific stages of development and the effects may be limited to a 
narrow range of cells in the brain. 

Brain Systems  
	With the advent of neuroimaging, we can, for the first time, 
look at the activity of brain circuits during illness and map how 
activity changes during recovery. Advances in neuroimaging in the 
past 5 years have provided more detailed pictures and the ability to 
see events almost in real time. For instance, imaging has recently 
revealed that a brain region called Area 25 is important in 
depression.  In depressed people, both volume and metabolic 
activity in this region are abnormal. As people recover from 
depression, activity in Area 25 undergoes significant changes.  
Whether the treatment is an antidepressant medication, behavioral 
therapy, or deep brain stimulation, recovery is associated with a 
reduction in the activity of this brain circuit.  

Clinical trials
	In addition to searching for new targets for treatments to help 
people in the future, we have been working to use current 
treatments more effectively, identifying those who will respond 
best to the treatments available now.  Over the past seven years, 
NIMH has completed several practical clinical trials that are the 
largest and longest of their kind, involving more than 10,000 
patients at more than 200 sites.  These studies were designed to 
examine not only changes in symptoms but changes in functioning, 
to determine whether a treatment improves quality of life, care 
giving burden, or use of health services. 
	These studies have already demonstrated the effectiveness of 
antidepressant medication for adolescents with depression and the 
value of an off-patent, inexpensive antipsychotic medication for 
adults with chronic schizophrenia. These clinical trials are part of a 
rigorous effort to discover what therapies work best, and for 
whom. Current research is discovering how individual differences 
in biology could determine how that person reacts to a certain 
medication. Discovering these individual differences will help 
improve and personalize both diagnosis and treatment.  For a 
person with mental illness, one can imagine that in the future a 
physician would perhaps use a memory task together with brain 
imaging and a genetics test to diagnose and select a specific 
treatment -- just as a contemporary cardiologist uses a stress test 
and echocardiogram to diagnose heart disease and select the proper 

	It is critical to realize that this vision of personalized care does 
not mean designing exotic therapies for a few privileged patients. 
The ultimate goal is personalized care for the full spectrum of 
people with mental disorders. As researchers learn more about the 
brain mechanisms of mental disorders and related behavioral and 
environmental factors, treatments will become more specific.  
	These are some of the issues that will be addressed by the 
newest generation of NIMH researchers. In the 60 years of 
NIMH's history, there has not been a more exciting time.  We are 
on the verge of significant advances that will move us closer to 
predictive, preventive, and personalized mental health care 
grounded in research.
	  We are also striving to assure that evidence-based practices 
can be disseminated and delivered, so that people have access to 
treatment and services that are coordinated and effective.  We are 
working within NIH to better integrate psychiatry with the rest of 
medicine, for they are inextricably linked:  stress and depression 
are major risk factors for heart disease and other serious medical 
conditions.  The mechanisms underlying these relationships are not 
yet clear, but integration will be a significant step toward improved 
care of the whole person by an effective treatment team.
	I firmly believe we have made a great start in understanding 
mental illnesses and that in our lifetimes we will be able to treat 
and even prevent mental illnesses with much greater certainty and 
speed.  This will restore productivity, make families whole, and 
eliminate many of the 30,000 suicide deaths each year.
	Thank you for providing me the opportunity to discuss these 
issues with you.  I will be happy to answer any questions you may 

        MR. DEAL.  Thank you.  
        Dr. DePaulo.
        DR. DEPAULO.  Chairman Deal, Representative Baldwin, 
Representative Myrick, thank you very much for holding these 
hearings and thank you for inviting all of us to speak this morning.  
        I am Ray DePaulo, Professor and Chairman of the Department 
of Psychiatry at Johns Hopkins, and I have been lucky enough to 
focus my own clinical and research career on bipolar disorder and 
depression.  And that is what I will focus my remarks on today.
        Because of this focus and the ability to do these sorts of things 
at a place like Johns Hopkins, I have now had the chance to see 
about 10,000 patients with depression and bipolar disorder.  
        I know from seeing them, but also from the research we have 
done on the brain and the genetics research I have participated in, 
that these are certainly brain diseases, as certainly as pneumonia 
and asthma are lung diseases.  
        I am also confident that, as Dr. Insel has laid out for you, that 
research can illuminate the molecular pathways to these diseases 
and that those molecular pathways will provide for us a way to 
design better diagnoses, better treatments and attempt prevention.  
        If I can show my first slide, I want to make a little bit of the 
case that depression, if you will, bipolar disorder and we can 
certainly say schizophrenia are the cancer of the 21st Century.  
Going back to the 1960s when I was a medical student at Johns 
Hopkins, I can tell you, cancer was prevalent then, and it is 
certainly prevalent today.  Both have a rate of somewhere in the 
range of 5 to 10 percent.  Both of these diseases, as has been said 
several times, have great impact on families, not just the patients.  
        Cancer was stigmatized, and depression still is.  In 1960, there 
was very little support for research on cancer.  It was a mysterious 
disorder, and people thought it was hopeless.  Today, research on 
depression and other psychiatric disorders is still under-supported.  
Are they mysterious?  Yes.  Are they hopeless?  Absolutely not.  
        The cancer treatments in 1960 were not very effective, and 
they were very poorly understood.  Our treatments for depression 
and bipolar disorder and schizophrenia today are fairly effective, 
not as effective as we would like and not as good as they should 
be, but they are very poorly understood.  We don't know why they 
work when they work and why they fail when they fail.  
        Next slide.  The World Health Organization has now included 
mental illnesses on its list of diseases to study around the world.  
They have shown that of the top ten causes of disability 
worldwide, five of them are mental disorders.  Unipolar or major 
depression, that is, major depression is number one on their list.  
Alcoholism is number four.  Bipolar disorder by itself is number 
six.  Schizophrenia is number nine, and obsessive-compulsive 
disorder is ten.  That is a very telling feature.  They wouldn't have 
seen that if they didn't include these.
        The next slide.  Another part from their study is to look at the 
ten leading causes of social burden in the developed countries, and 
again, I apologize that these are not easy to see, but four or five of 
these are clearly related to mental health.  Unipolar depression 
again is number two.  Road traffic accidents, which are highly 
involved with alcohol and alcoholism, are four and five on that list.  
Dementias due to Alzheimer's and other diseases are number eight, 
and self-inflicted injuries are number nine on the causes of total 
social burden on society.  
        You have also heard that depression by itself is an independent 
risk factor, an important one for heart attacks and for strokes.  So 
these are medical diseases, and they lead to other medical diseases.  
The next slide, some numbers and again hard to read on your 
monitor, is that the ultimate cost of these disorders is, as Tom Insel 
has said, is suicide.  
        Actually, what I think is the best population study of suicide 
ever done was done in a little town in Sweden where everybody 
was interviewed by psychiatrists three times 25 years apart.  Over 
those 25 years, they kept track of lots of things that happened to 
these people, including suicide.  
        The good news is that 75 percent of the interviews had no 
psychiatric diagnosis, but the revealing thing is that suicide rates in 
people with any psychiatric disorder were ten times greater than 
the population rate.  For those with bipolar disorder and 
depression, they were 80 times greater.  
        So this is a dose response curve to show you the impact of 
these diseases.  
        Let me conclude with my last slide and again talk about 
depression which I believe is the cancer of the 21st Century.  It was 
cancer biology, the molecular biology of cancer, and 
epidemiology, that is population or public health studies, that 
illuminated the genetic and environmental pathways to cancer and 
have created logical treatment and prevention strategies for cancer.  
        The cancer centers, very important, clinical cancer centers have 
conducted the largest and best done clinical trials of treatments that 
have ever been done in the world anywhere, and I am saying this 
because I think this is what our future should be in mental 
disorders as well.  
        Depression biology is human brain biology, and as Dr. Insel 
has noted, that is now possible, and it is occurring, and we are in 
the early days, but it is occurring.  What we need is to take those 
tools and turn them into what is called translational research.  
Translational research, a term that comes from cancer research by 
the way and the war on cancer, means developing new 
interventions, new diagnoses, markers, and treatments based on 
what we discover in the biology of the disorder.  This is really 
        So what do we need to do that?  What we need to do is, 
certainly, yes, more research.  That will require more funds, but it 
requires more than that.  We also need more careers devoted to 
these disorders, and we need more public education.  
        I really appreciate both the turnout here but also the statements 
that the Members have made that said that public education is a 
priority for all of us.  
        As well, we do depend, because these are diseases, on the 
general progress of medical research, both at the level of molecules 
and at the level of public health.  I want to thank you for the 
opportunity to testify today. 
        [The prepared statement of Dr. Raymond DePaulo follows:] 


        Representative Deal, Ranking Member Brown, Mrs. Myrick 
and the Members of the Health Subcommittee:  I am Ray DePaulo, 
Henry Phipps Professor and Chairman of the Department of 
Psychiatry at The Johns Hopkins University School of Medicine.  
I'm pleased to be invited here to speak about mental illness and 
brain disease.  I have spent the last 30 years as a clinician, 
research, and teacher at Johns Hopkins focused on Depression and 
Bipolar Disorder, which are two of the serious brain diseases 
referred to as "mental illnesses".  I will describe the prevalence and 
costs of these 2 conditions. I will explain why we are convinced 
that these are diseases of the brain (as surely as pneumonia and 
asthma are diseases of the lungs) and why I am confident that 
research will illuminate the molecular and structural pathways to 
these brain diseases and lead to much better ways to diagnose, treat 
and, in some cases, prevent these disabling diseases.  
        Major depression and bipolar disorder make up what are called 
mood disorders. The most recent estimate is that about 10% of 
Americans (and about 5% of adolescents) have had at least one 
episode of depression in their lifetime (Kessler et al, 2005).  Most 
will have multiple episodes of depression and one in 10 of them 
will have one or more severe manic episodes.   When depressed, 
patients experience a low, anxious, or apathetic change in their 
mood, inability to enjoy things that normally give them satisfaction 
or pleasure, a loss of energy, reduced ability to sustain attention & 
concentration, as well as a very negative change in their view of 
themselves and of the future.  These symptoms, if untreated, last 
for several weeks up to a few years and like asthma or epilepsy 
once begun, they tend to recur. Most worrisome, patients with 
severe depressions often contemplate or attempt suicide.  Of those 
who complete suicide most have depression and 90% have one or 
more diagnosable mental disorders based on information gathered 
about them prior to the suicide.   Before he served in Congress, 
Abraham Lincoln had 2 well-documented periods of depression (or 
melancholia as it was called then).  During these 2 periods, each 
lasting several months,  he was taken in by relatives on a farm in 
Kentucky where someone was always with him to keep him from 
throwing himself into the river.  But everyone has moods and some 
must be worse than others. Why do we say that clinical forms of 
depression, namely major depression and bipolar disorder are brain 
diseases?  As defined in Webster's dictionary, a disease is a set of 
clinical symptoms that are directly attributable to an abnormal 
body part (called pathology).  The part of the brain that is 
malfunctioning in depression is not a single spot but a set of 
circuits in the brain in the frontal areas that are known because of 
both modern brain imaging methods show this (Mayberg et al , 
2005; Drevets et al, 1997; House et al, 2000) but also from the 
known brain lesions of Parkinson's Disease and of stroke. Over 
half of patients with Parkinson's disease (which injures the basal 
ganglia in the subcortical regions of the frontal lobes) experience 
episodes of depression after their Parkinson's disease onsets and in 
stroke patients; the likelihood of clinical depression in the 
immediate aftermath is related to which area of the brain is injured 
by the stroke.  Most cases of depression though are not caused by 
direct injuries to the brain, but by a combination of genetic and 
environmental factors that affect the structure and function of key 
circuits in the frontal areas of the brain.  In this sense, depression is 
like asthma, it's largely genetic in origins but its exacerbations are 
usually caused by changes in the environment. For asthma patients 
this is often dust or pollen while for depressed patients 
psychological stressors are the most frequent environmental 
triggers.  For asthma patients, when a severe attack occurs, 
removal of the dust or pollen is not sufficient therapy; medical 
treatment is needed to bring the patient back to normal breathing.  
Severe depression it is the same, the patient will need counseling 
and medications usually to achieve a remission sufficient to return 
to functioning. And longer term treatment between episodes is 
needed for many patients with asthma and with depression.  
Because we cannot as physicians control the flow of pollen or 
psychological stresses (which by themselves are not bad things for 
most people) it is important that we find the genes whose 
malfunction is ground zero on the pathway to these diseases.  In 
depression because we don't understand why our medications help 
when they do help and why they fail in other cases, we need the 
molecular clues that genes can provide to make our treatments 
more effective.  Genes which are molecules of DNA direct cells to 
make particular proteins. The proteins make up the structure of 
brain cells, brain pathways and circuits, and when they 
malfunction they make the brain vulnerable to stresses which can 
set off episodes of psychiatric illnesses such as depression.   
Understanding how this works can't help but make us better at 
making diagnoses and giving the right treatments to the right 
patients. The molecular formulas should tell us much about which 
patients will respond to which of today's treatments and which will 
not.  They should also guide us to create new treatments which 
would be "engineered" rationally based on knowledge of what is 
wrong in the brain, not just in the emotions or behavior of the 
        Depression and bipolar disorders are common diseases like 
cancer and like cancer they have many different forms caused by 
several different genes and several distinct environmental toxins 
acting in combination.   Like cancer, therefore, the big 
breakthroughs will not be cheap or easy and we can expect 
challenges at many steps.  The War on Cancer was the right 
decision by Congress at the right time (1971) and it has led to a 
great deal of progress so that cancer deaths are finally falling and 
many forms of cancer are now detected early and cured and even 
severe cancers can be managed much better than they were 35 
years ago.   The key breakthrough that made the war on cancer 
possible was the discovery of the genetic code (called codons) 
which allowed pathologists who looked at tumors under the 
microscope see where the cellular mechanisms went astray, in the 
DNA, the RNA, or at the protein level itself.   Thus pathologists 
and cancer experts could "interrogate" the tumors.  However this 
technology was not sufficient to allow us to interrogate the living 
brain. Now with the genome project largely completed and the 
brain imaging methods progressing (and incorporating the imaging 
of proteins in the brain) we can now see how we might look into 
the mechanisms of depression like we have illuminated so much of 
the pathway to various forms of cancer.  And as we have done with 
cancer patients, we now are much better at predicting which 
patients will respond to old treatments (radiation and hormonal 
manipulations) and we have also devised many new treatment 
strategies (immune therapies and new less toxic chemotherapies) 
that we never imagined before the  molecular war on cancer was 
	This description of depression (and Bipolar disorder) as today's 
"cancer" is very appropriate.  When I started medical school at 
Johns Hopkins in 1968, there were only 4 cancer doctors on the 
staff. Cancer was a word that many doctors would not utter to their 
patients with cancer for fear of the stigma.  Patients who were 
admitted with late "metastatic" cancers were often put in the room 
farthest from the doctors and nurses, not because the doctors or 
nurses didn't like them, but because they didn't know what to say 
and they thought there was nothing useful that they could do.   
Today, we understand cancer and although it is still a serious and 
often fatal condition there is no sense of cancer as a death sentence 
or as a stigma on the family whose relative suffers from it.  At 
Johns Hopkins now there are over 200 cancer doctors and now 3 
cancer buildings, reflecting the progress and the optimism we have 
about further progress in cancer.  It has not been cheap or easy 
going. Cancer has not been eradicated and may never be fully 
eradicated but no one can deny the progress and the difference it 
has made to patients, families, and to society.   We understand it so 
much better and, therefore, we are continuing to find new ways to 
prevent it, to detect it early, to cure it, and to make life meaningful 
and substantial as we manage some forms of it now as a chronic 
disease rather than as a death sentence.  
        The World Health Organization global burden of disease study 
has demonstrated that depression is the leading cause of disability 
world wide and that 5 of the top ten causes of disability are 
psychiatric disorders (depression, alcoholism, bipolar disorder, 
obsessive compulsive disorder, and schizophrenia).  It has 
predicted that by 2020 depression will be "the second most 
debilitating disease worldwide, after ischemic heart disease, and 
one of the leading causes of death, as suicide takes more lives than 
traffic accidents, lung disease, or AIDS."  Cardiovascular disease 
receives the largest amount of government funding, 25 percent; 
diabetes gets about 8 percent and cancer a little over 6 percent, 
while all mental illnesses (which includes all of the conditions 
noted by the W.H.O. and many more)   receives only 4 percent.  
	Of those who suffer from depression year, approximately 74% 
(or 7.8 million) of them are in the workforce.  This has numerous 
implications as far as the potential strength of our economy, should 
this group of individuals have access to the mental health care they 
require.  Furthermore, workers with depression have a much higher 
rate of missed days than their healthy counterparts.  On average, 
depression accounts for a 2.5 fold increase in the probability of 
missing work as a result of their illness (Langlieb and Kahn 2005).   
In 2000, depression alone was estimated to cost the US economy 
$83.1 billion each year , most of it due to absenteeism and 
decreased productivity at work (Greenberg et al 2003).  
        The issue of mental health care is particularly timely as our 
nation is in the midst of the War on Terrorism.  The primary goal 
of terrorism is not simply kill Americans, which can be done only 
on a small scale by our adversaries.  The goal is to wage 
psychological war that will sap our citizen's morale and 
confidence in our civilization.  Although depression and many 
forms of anxiety disorders have strong genetic components they 
also have strong environmental triggers.  The events of September 
11, 2001 created an enormous amount of mental anguish for those 
working in and living around the World Trade Center and the 
Pentagon.  Numerous studies were published soon after these 
events describing both civilian and military response to these 
unspeakable attacks.  Among of the 1008 adults randomly 
telephoned who reside near the World Trade Center, "9.7 percent 
reported symptoms consistent with current depression" (Galea et al 
2002: 982).  In a study on civilian and military employees of the 
Pentagon, 17.7 percent of respondents reported depressive 
symptoms following the attack events of 9/11 (Jordan et al 2004).  
This rate is higher when you examine the experiences of military 
personnel returning from the war in Iraq.  When examined for 
mental health following deployment to Iraq, 19.1 percent of those 
questioned screened positive for depression (Hoge et al 2006).  
These numbers indicate a strong need for mental health care 
among those indirectly and directly affected by the events on and 
following September 11, 2001.  It should be noted, as well, that a 
recent article in the New York Times reported an epidemic of 
depression and post-traumatic stress disorders in New Orleans 
following Hurricane Katrina.  This mental health epidemic has lead 
to a three-fold increase in the suicide rate from that before the 
hurricane (Saulny 2006).  Lack of resources in this area is 
compounding the problem and greatly taxing local mental health 
	The need for research on disorders of mood disorders (and the 
other mental disorders as outlined by Dr Insel) is vital for our 
troops and to all American citizens.    About 15 million people (10 
million women and 5 million men) in the United States at any 
given time have major depression or some form of manic 
depression.  The prevalence for depression runs very high, as do 
the costs to the individual and the country as a whole.  It is 
imperative that we invest more time and money towards this 
"Cancer of the 21st Century," so that treatments can lead to cures 
and hopes into reality.

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often tied to cardiac incidents, but reasons unclear. The 
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DePaulo, Jr., J.R., Horvitz, L.A. Understanding Depression: What 
we know and what we can do about it. New York: John Wiley & 
Sons, Inc, 2002.

Dinos, S., Stevens, S., Serfaty, M., Weich, S., King, M. Stigma: 
The feelings and experiences of 46 people with mental illness. 
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Fenton, W.S., Stover, E.S. Mood Disorders: Cardiovascular and 
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Gold, J., Vlahov, D. Psychological Sequele of the September 11 
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Medicine 346: 932-987, 2002.

Greenberg, P.E., Kessler, R.C., Birnbaum, H.G., Leong, S.A., 
Lowe, S.W., Berglund, P.A., Corey-Lisle, P.K. The economic 
burden of depression in the United States: how did it change 
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Goetzel, R.Z., Ozminkowski, R.J., Sederer, L.I., Mark, T.L. The 
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1023-1032, 2006.

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Egerton, W.E. Mental Health Impact of 9/11 Pentagon Attack: 
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Kessler, RC, Demler, O., Frank, RG, Olfson, M, Pincus, HA, 
Walters, EE,
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Langlieb, A.M., Kahn, J.P. How Much Does Quality Mental 
Health Care Profit Employees? Journal of Occupational and 
Environmental Medicine 47: 1099-1109, 2005.

Langlieb, A.M., Druss, B.G., Rosenheck, R. Cost-Effectiveness, 
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        MR. DEAL.  Thank you.  
        Dr. Jamison. 
        DR. JAMISON.  Yes, I am delighted to be here.  Thank you, 
Mr. Chairman.  Thank you, Ms. Myrick.  Someone called her a 
great agitator.  She is a great agitator and a wonderful human being 
who has been very supportive of mental health causes.  
        My name is Kay Redfield Jamison, and I am a Professor of 
Psychiatry at the Johns Hopkins School of Medicine.  My clinical 
and research interests lie in the study of mood disorders, especially 
bipolar disorder, and in the study and prevention of suicide.  
        My written testimony includes some basic information about 
bipolar disorder, but I am here really to talk about my own 
experiences with manic depressive illness and to strongly advocate 
for increased research funding.  
        Although we know much more about this illness than even 5 
years ago, thanks in significant measure to the excellent research 
efforts of NIMH, there is far too much we do not know.  Only an 
aggressive and concerted effort to study the underlying causes of 
bipolar illness, particularly genetics, will result in earlier and more 
accurate diagnosis and better treatment.  
        But I would like to speak now at a more personal level.  Like 
most people, I had absolutely no reason to expect that I would 
become so seriously, so terribly mentally ill.  I certainly had no 
preparation for insanity.  No one does.  I came from a military and 
very traditional family, and although I have a very extensive 
family history of bipolar illness, nobody in my family talked about 
        I had a healthy, active, and very happy childhood and 
adolescence.  I loved school and did well at it.  I loved sports, was 
a school leader and captain of all my teams.  Then in my senior 
year of high school, after a period of much, much, much 
enthusiasm and not much sleep, I became deeply depressed, 
suicidal, and psychotic.  I had never thought of suicide or death 
before, and now I thought of little else.  For much of each day, 
during several months of my senior year in high school, I thought 
about when, whether, and how to kill myself.  
        Over the years, my manic-depressive illness became much, 
much worse, and the reality of dying young from suicide became a 
dangerous undertow in my dealings with life.  Then when I was 28 
years old, after a particularly damaging and psychotic mania 
followed in turn by a particularly prolonged and violent siege of 
depression, I took a massive and, because I was a lithium 
researcher, what I knew to be a lethal overdose of lithium.  I 
unambivalently wanted to die.  I nearly did die.  I was in a coma 
for many days.  
        Yet I have been fortunate.  My illness responds very well to 
lithium, and I have been well for more than 20 years.  I have had 
the best medical care available.  I have had access to that care, and 
I have been able to afford to pay for that care.  Most people cannot.  
My family, friends, and colleagues have been surpassingly 
supportive.  Most people are not so lucky.  I would like to end with 
a few beliefs and a few concerns.  
        As a clinician, I believe there are treatments that can and do 
save lives.  As one surrounded by scientists whose explorations of 
the brain are eloquent and profound, I believe that our basic 
understanding of the brain's biology is radically changing how we 
think about both mental illness and suicide.  As a teacher of young 
doctors and graduate students, I feel the future holds great promise 
for the intelligent and compassionate care of the seriously mentally 
        Still, the effort to develop new treatments for severe mental 
illness and to prevent suicide seem to me to be remarkably 
unhurried.  Every 17 minutes in America, someone commits 
suicide.  Where is the public outrage?  Where is the public 
concern?  I have become more impatient in recent years, and I 
didn't start off particularly patient, and I am more acutely aware of 
the problems that stand in the way of denting the death count.  I 
cannot rid my mind of the desolation, confusion, and guilt I have 
seen in the parents, children, friends, and colleagues of those who 
kill themselves.  Nor can I shut out the images of the autopsy 
photos I have seen of 12-year-old children or the prom 
photographs of teenagers who will within a year's time put a pistol 
in their mouths or jump from the top floor of a university 
dormitory building.  
        Looking at suicide, the sheer numbers, the pain leading up to it, 
and the suffering left behind, is harrowing.  For every moment of 
education and exhilaration in the science or in the success of 
governments, there is the matching and terrible reality of the 
deaths themselves: the young deaths, the violent deaths, the 
terribly unnecessary deaths.  
        Like many of my colleagues who study mental illness and 
suicide, I have seen time and again the limitations of our science.  I 
have been privileged to see how good some doctors are and 
dismayed by the incompetence of others.  Mostly, I have been 
impressed by how little value our society puts upon saving the 
lives of those who are in such despair as to want to end them.  
        It is a societal illusion that suicide is rare.  It is not rare.  
Certainly the mental illnesses most closely tied to suicide are not 
rare.  They are common conditions.  And unlike cancer and heart 
disease, they disproportionately affect and kill the young.  The tens 
of millions of Americans who suffer from mental illness deserve 
compassion and good science.  The diseases from which they 
suffer deserve to be given the kind of research funding 
commensurate with the pain and death they cause.  In short, they 
deserve action.  
        Thank you. 
        [The prepared statement of Dr. Kay Jamison follows:] 


	Good morning.  My name is Kay Redfield Jamison and I am a 
professor of psychiatry at the Johns Hopkins School of Medicine 
and co-director of the Johns Hopkins Mood Disorders Center.  I 
received my Ph.D. from the University of California, Los Angeles 
in clinical psychology, with a specialization in 
psychopharmacology.  My clinical research interests lie in the 
study and treatment of mood disorders � depression and bipolar 
disorder�and in the study and prevention of suicide. I have also 
studied creativity and literature and have an appointment as 
Honorary Professor of English at the University of St. Andrews in 
Scotland.  I am here today to speak about my own experiences 
with manic-depressive illness, also called bipolar disorder, and to 
strongly advocate for increased research funding for psychiatric 
illnesses.  Before turning to my own experiences, I would like to 
give a very brief overview of what we know about bipolar 
	Manic-depression, or bipolar disorder, is a painful, common, 
and potentially lethal disorder of mood, thinking, energy, and 
sleep.  It ranges tremendously in severity, from relatively mild 
expressions to extremely severe, life-threatening and psychotic 
forms of the illness.  The depressive phase - like depression itself 
- is characterized by a profound lack of energy, apathy, 
hopelessness, sleeping far too much or far too little, difficulties in 
thinking, and a loss of pleasure in life.  Suicidal and morbid 
thoughts, as well as undue guilt, are common.
	The manic phase is characterized by symptoms in many ways 
the opposite of those seen in depression.  Mood is elevated and 
expansive, or paranoid and irritable; activity and energy levels are 
greatly increased; the need for sleep is decreased; speech is fast 
and excitable, and thinking is very rapid.  Other common features 
of mania are spending large amounts of money, impulsive 
involvement in questionable endeavors, impatience, and volatility.  
In its extreme forms mania is characterized by violent agitation, 
bizarre behavior, delusional thinking, and hallucinations.
	What, briefly, do we know about the causes, correlates, and 
treatment of bipolar illness?  First, we know it is genetic.  It runs in 
families.  The scientific evidence that bipolar disorder is biological 
is indisputable.  We also know also that the illness is potentially 
lethal.  The mortality rate is very high.  The suicide rate in 
untreated, severe bipolar illness is 10-15%; 25-50% of people 
with the disorder will attempt suicide at least once.  It has been 
estimated that at least 70% of the adolescents who commit suicide 
suffered from a potentially treatable, major mood disorder.
	Bipolar illness, like virtually all of the major psychiatric 
disorders, is an illness of youth; that is, the illness most frequently 
first occurs in late adolescence or the early twenties.  The average 
age of onset is about 18 years. Men and women are equally liable 
to bipolar disorder, and alcohol and drug abuse are common.  The 
illness is recurrent and, if not treated, is often progressive; that is, it 
will tend to worsen over time. About one percent of the population 
will develop the more severe form of bipolar illness; perhaps two 
to three percent will have milder forms.
	Finally, and most important, bipolar illness is treatable.  Most 
patients will respond to lithium, anticonvulsants, or a combination 
of anticonvulsants, lithium, and antipsychotic medications. 
Unfortunately, and unfairly, many people do not have access to 
good medical care, nor can they afford to pay for the medications 
that have been prescribed for them.
	Although we know much more about this illness than we did 
even five years ago - thanks in significant measure to the 
excellent research efforts of the National Institute of Mental 
Health-there is far too much we do not know.  Only an 
aggressive and concerted effort to study the underlying causes of 
bipolar illness will result in earlier and more accurate diagnosis 
and better, less problematic treatments.
	I would like to speak now at a more personal level. Like most 
people, I had no reason to expect that I would become so seriously, 
so terribly mentally ill.  I certainly had no preparation for insanity.  
I came from a military and traditional family and,  although I had a 
very extensive family history of bipolar illness, no one talked 
about it.  I had a healthy, active, and very happy childhood and 
adolescence.  I loved school and did well at it, loved sports, was a 
school leader, and captain of all of my teams.  
	Then, in my senior year of high school, after a period of much 
enthusiasm and not much sleep, I  became deeply depressed, 
suicidal, and psychotic.  I had never thought of suicide before; now 
I thought of little else.  For much of each day during several 
months of my senior year in high school, I thought about when, 
whether, where, and how to kill myself.  I learned to present to 
others a face at variance with my mind; ferreted out the location of 
two or three nearby tall buildings with unprotected stairwells; 
discovered the fastest flows of morning traffic; and learned how to 
load my father's gun.
	The rest of my life at the time - sports, classes, writing, 
friends, planning for college - fell fast into a black night.  
Everything seemed a ridiculous charade to endure; a hollow 
existence to fake one's way through as best one could.  But, 
gradually, layer by layer, the depression lifted, and, by the time my 
senior prom and graduation came around, I had been well for 
months.  Suicide had withdrawn to the back squares of the board 
and become, once again, simply unthinkable.
	Over the years, my manic-depressive illness became much, 
much worse, and the reality of dying young from suicide became a 
dangerous undertow in my dealings with life.  Then, when I was 
twenty-eight years old, after a particularly damaging and psychotic 
mania, followed, in turn, by a particularly prolonged and violent 
siege of depression, I took a massive, and what I knew to be a 
lethal overdose of lithium.  I unambivalently wanted to die, and 
nearly did.  Death from suicide had become a possibility, if not 
probability, in my life.
	Yet I have been fortunate.  My illness responds very well to 
lithium and I have been well for more than twenty years. I have 
had the best medical care available and I have been able to afford 
to pay for it.  My family, friends and colleagues have been 
surpassingly supportive; most people are not so lucky. 
	I would like to end with a few beliefs and concerns. As a 
clinician, I believe there are treatments that can save lives; as one 
surrounded by scientists whose explorations of the brain are 
elegant and profound, I believe that our basic understanding of the 
brain's biology is radically changing how we think about both 
mental illness and suicide; and, as a teacher of young doctors and 
graduate students, I feel the future holds out great promise for the 
intelligent and compassionate care of the seriously mentally ill.
	Still, the effort to develop new treatments for severe mental 
illness and to prevent suicide seems remarkably unhurried.  Every 
seventeen minutes in America, someone commits suicide.  Where 
is the public concern and outrage?  I have become more impatient 
in recent years, and am more acutely aware of the problems that 
stand in the way of denting the death count.  I cannot rid my mind 
of the desolation, confusion, and guilt I have seen in the parents, 
children, friends, and colleagues of those who kill themselves.  Nor 
can I shut out the images of the autopsy photographs of twelve-
year-old children, or the prom photographs of adolescents who 
within a year's time will put a pistol in their mouths or jump from 
the top floor of a university dormitory building.  Looking at suicide 
- the sheer numbers, the pain leading up to it, and the suffering 
left behind - is harrowing.  For every moment of celebration for 
the science, or in the success of governments, there is a matching 
and terrible reality of the deaths themselves: the young deaths, the 
violent deaths, the unnecessary deaths.
	Like many of my colleagues who study mental illness and 
suicide, I have seen time and again the limitations of our science, 
been privileged to see how good some doctors are, and dismayed 
by the incompetence of others. Mostly, I have been impressed by 
how little value our society puts upon saving the lives of those who 
are in such despair as to want to end them.  It is a societal illusion 
that suicide is rare.  It is not.  Certainly the mental illnesses most 
closely tied to suicide are not rare.  They are common conditions, 
and, unlike cancer and heart disease, they disproportionately affect 
and kill the young.  
The tens of millions of Americans who suffer from mental illness 
deserve compassion and good science. The diseases from which 
they suffer deserve to be given the kind of research funding 
commensurate with the pain and death they cause. In short, they 
deserve action.

Attachment:  Biographical sketch 

Kay Redfield Jamison

	Kay Redfield Jamison is Professor of Psychiatry at the Johns 
Hopkins University School of Medicine and co-director of the 
Johns Hopkins Mood Disorders Center. She is also Honorary 
Professor of English at the University of St. Andrews in Scotland.  
She is the coauthor of the standard medical text on manic-
depressive illness, which was chosen in 1990 as the Most 
Outstanding Book in Biomedical Sciences by the American 
Association of Publishers, and author of Touched with Fire, An 
Unquiet Mind, Night Falls Fast, and Exuberance.  Her memoir 
about her experiences with manic-depressive illness, An Unquiet 
Mind, was cited by several major publications as one of the best 
books of 1995.  An Unquiet Mind was on The New York Times 
Bestseller List for more than five months and translated into 
twenty languages. Night Falls Fast: Understanding Suicide was a 
national bestseller, translated into fifteen languages, and selected 
by The New York Times as a Notable Book of 1999.  Her most 
recent book, Exuberance: The Passion for Life, was selected by 
The Washington Post, The Seattle Times, and The San Francisco 
Chronicle as one of the best books of 2004 and by Discover 
magazine as one of the best science books of the year.
	Dr. Jamison did her undergraduate and doctoral studies at the 
University of California, Los Angeles where she was a National 
Science Foundation Research Fellow, University of California 
Cook Scholar, John F. Kennedy Scholar, United States Public 
Health Service Pre-doctoral Research Fellow, and UCLA Graduate 
Woman of the Year.  She also studied zoology and 
neurophysiology at the University of St. Andrews in Scotland.
	Dr. Jamison, formerly the director of the UCLA Affective 
Disorders Clinic, was selected as UCLA Woman of Science and 
has been cited as one of the "Best Doctors in the United States".  
She is recipient of the American Suicide Foundation Research 
Award, the UCLA Distinguished Alumnus Award, the UCLA 
Award for Creative Excellence, the Siena Medal, the Endowment 
Award from the Massachusetts General Hospital/Harvard Medical 
School, the Fawcett Humanitarian Award from the National 
Depressive and Manic-Depressive Association,  the Steven V. 
Logan Award for Research into Brain Disorders from the National 
Alliance for the Mentally Ill, the William Styron Award from the 
National Mental Health Association, the Falcone Prize for 
Research in Affective Illness from the National Alliance for 
Research on Schizophrenia and Depression, and the Yale 
University McGovern Award for excellence in medical 
communication. She has been awarded numerous honorary 
degrees, selected as one of five individuals for the public television 
series "Great Minds of Medicine", and chosen by Time magazine 
as a "Hero of Medicine".  She was Distinguished Lecturer at 
Harvard University in 2002 and the Litchfield Lecturer at the 
University of Oxford in 2003. She is the recipient of a MacArthur 
	Dr. Jamison was a member of the first National Advisory 
Council for Human Genome Research.  She is Senior Scientific 
Consultant to the Dana Foundation and Chair of the Genome 
Action Coalition, an alliance of more than 140 patient groups, 
pharmaceutical corporations, and biotechnology companies.  She 
also serves on the National Committee for Basic Sciences at 
UCLA and is the executive producer and writer for a series of 
award-winning public television specials about manic-depressive 
illness and the arts.

        MR. DEAL.  Unfortunately, those bells mean we have another 
vote on the floor.  People are playing games this morning.  We 
have a motion that the committee rise that we have to go vote on.  
        Dr. Gooding, rather than try to hurry your testimony, we will 
go vote and come back and resume with your testimony after we 
        MR. DEAL.  The hearing will reconvene.
        Dr. Gooding.
        DR. GOODING.  Thank you.  Good morning, Chairman Deal 
and members of the subcommittee.
        My name is Diane Gooding, Associate Professor of 
Psychology and Psychiatry at the University of Wisconsin, 
        My primary areas of research are identifying and validating 
indicators of heightened risk for schizophrenia and then identifying 
and studying at-risk individuals.  While summarizing current 
schizophrenia research, I would like to illustrate the ways in which 
focusing on genetic markers at risk for schizophrenia can help us 
to better understand and combat this devastating mental disorder.  
        Although there are currently some palliative treatments for 
schizophrenia, the specific biological mechanisms underlying the 
disorder are currently unknown, and the goals of schizophrenia 
research are focused on identifying the pathophysiology and 
etiology of the disorder and eventually preventing the disorder.  
        Contrary to earlier notions about schizophrenia, it is not due to 
bad parenting or personal failure.  Schizophrenia is an equal 
opportunity disorder.  It affects people of all socioeconomic 
groups, ethnicities, and races.  
        The typical age of risk is between late adolescence and early 
adulthood, and the consensus right now is that schizophrenia is a 
genetically mediated neurodevelopmental disease.  We know that 
genes are necessary but not sufficient for the development of 
        As a group, people with schizophrenia differ from healthy 
people in terms of their neurocognitive performance.  People with 
schizophrenia show impairments in terms of executive functioning.  
For example, attention, inhibition, response planning, different 
types of memory, eye movements, information processing, and 
sensory gating.  
        We know that some of these neurocognitive impairments have 
the following characteristics:  The ones that we see in 
schizophrenia in disproportionate numbers are relatively rare in the 
general population.  They are heritable, and they are stable over 
        In the schizophrenia patients, these abnormalities are present 
during acute episodes as well as during symptom remission, and 
they are independent of medication status and chronicity.  Also, 
these same abnormalities are present in higher proportions of the 
clinically unaffected biological relatives of the patients.  
        When neurocognitive impairments have all of these 
characteristics, we consider them to be markers of a genetic 
liability for schizophrenia, and we call markers of genetic liability 
        It is really exciting right now in research because we are 
making a lot of progress in terms of identifying such 
endophenotypes.  Examples would be eye-tracking abnormalities, 
working memory impairments, and sensory gating deficits.  
        Why would we want to study these?  What are the advantages?  
Because these endophenotypes, these markers of genetic risk, are 
closer in the etiologic chain than symptoms, these markers can be 
an invaluable aid in the genetic dissection of the disorder.  
Currently, we know that genes are involved, but we don't know 
which genes are involved, how many genes need to be present, and 
how they affect brain development.  
        We also know that not everyone at heightened risk for 
schizophrenia goes on to manifest the disorder, so we can study 
endophenotypes to identify those individuals of heightened risk 
and study them over time, follow them to try to figure out why 
among the vulnerable individuals some of them succumb to the 
disorder and others are spared.  
        Moreover, we can use the study of endophenotypes to 
investigate whether certain indicators that have predictive validity 
at the population level also have predictive validity at the 
individual level.  
        We know that palliative treatment of schizophrenia can lead to 
considerable improvements in terms of quality of life, ability to 
live and work in the community, and studies indicate that the 
shorter the duration of untreated psychosis, the better the chances 
for more positive outcome.  
        Currently, there are research projects that attempt to intervene 
with individuals who show schizophrenia-like functional deficits 
early on but have not yet experienced psychotic symptoms.  The 
goals of these early intervention programs are to detect early on 
emerging psychosis, to intervene to prevent further development of 
disfunction, psychological disfunction, to delay the onset of 
disorder if you can't prevent the further development of it and to 
reduce treatment delay at the first episode.  
        How do they get people into these studies?  Well, it is based on 
an accumulation of risk factors, and they use a statistical 
risk-oriented approach, but we still don't know who our target 
population should be for these prodromal studies, and this is where 
markers can come in.  
        Also, through the use of risk factors and endophenotypes, we 
would know which ones are the best screening tools for inclusion 
into these early trials and how soon we should be including people.  
So at this point, we know that schizophrenia is a genetic disorder, 
and we are investigating the different neurocognitive impairments 
to identify the biological underpinnings of the disorder.  
        It is gratifying to participate in dispelling myths about 
schizophrenia and then educating the public about the disorder.  
        Chairman Deal, thank you for the opportunity to provide 
testimony to the committee on this important health topic.  
        And thank you, Representative Sue Myrick and Representative 
Tammy Baldwin, for your ongoing support of research and 
education in improving the lives of people with mental illness. 
        [The prepared statement of Dr. Diane C. Gooding follows:] 


        Good morning, Chairman Deal, Chairman Barton, and 
members of the Subcommittee. Thank you for inviting me here 
today to provide testimony on the biological basis of 
schizophrenia.  My name is Diane Gooding, Associate Professor of 
Psychology and Psychiatry at the University of Wisconsin-
Madison.  My primary areas of research are:  identifying and 
validating indicators of heightened risk for schizophrenia and 
related conditions and identifying and studying individuals 
putatively at heightened risk for the disorder. 

Defining schizophrenia
        Schizophrenia is one of the most severe forms of 
psychopathology. It is a disorder that affects one's thoughts, 
feelings, goal-directed behaviors, social functioning, and even 
one's self-care.  Since the early observations of Kraepelin [1896] 
and Bleuler [1911], schizophrenia has been regarded as a primarily 
cognitive disorder of neurobiological origin. It is an equal 
opportunity disorder, affecting individuals of all races, ethnicities, 
and socioeconomic strata. Although its prevalence is relatively low 
(1.1% of population aged 18 and older; APA, 2000), clinicians and 
researchers often regard schizophrenia as the "cancer of the mental 
illnesses" due to its severity, chronicity, societal costs, and 
personal costs to affected individuals and their loved ones.  
Clearly, schizophrenia is an important public health concern.  
Although there are some palliative treatments for schizophrenia, 
the mechanisms underlying the disorder remain unknown. If the 
long term goal is to prevent schizophrenia, then an intermediate 
goal would be to identify the pathophysiology and etiology of the 

Diagnosing schizophrenia
        There is no direct measure of the neuropathology of 
schizophrenia at present.  Currently, the diagnosis of schizophrenia 
is made on the basis of symptoms, which are inferred based on the 
individuals' language and behaviors. There are symptoms which 
represent an exaggeration of normal functions, such as 
hallucinations, the false perception of sensory experiences (such as 
hearing voices, or seeing things that aren't there) and delusions, 
which are false beliefs that are persistent, unusual, and unshakable.  
Although most of the general public is aware of the florid 
symptoms of delusions and hallucinations, they have less aware of 
the symptoms of schizophrenia which represent the absence of 
normal functions and behaviors. These symptoms include 
amotivation/avolition (loss of motivation), anhedonia (loss of 
pleasure), alogia (reduced speech), affective impairments (such as 
loss or restriction of emotional display) and attentional 
impairment.  The clinical picture of schizophrenia varies from 
patient to patient.  Not all individuals with schizophrenia have the 
same constellation of symptoms and not all have the same severity 
of impairment.  Despite the apparent heterogeneity of 
schizophrenia, there is a core underlying deficit; the core deficit in 
schizophrenia is a cognitive one.

The genetic basis of schizophrenia
        Schizophrenia is not the result of the way in which a person is 
raised, nor is it the result of a personal weakness or failure on 
behalf of the affected person.  Contrary to earlier notions about the 
causes of schizophrenia (e.g., the schizophrenogenic,  ambivalent 
mother) schizophrenia is a genetically-based brain disorder. Family 
studies indicate that individuals who are biologically related to a 
person with schizophrenia are at much higher risk for developing 
schizophrenia.  The risk of developing schizophrenia for a person 
who is related to someone with schizophrenia increases as a 
function of how many genes they share in common.
        The role of genes in schizophrenia has been demonstrated by 
twin and adoption studies. In order to estimate the extent of the 
genetic component of any trait or disease,twin studies compare the 
concordance rate, or the likelihood of both twins having the same 
illness, between monozygotic (identical) and dizygotic (fraternal) 
twins.  The greater the monozygotic twin concordance compared to 
the dizygotic concordance, the greater the inherited component. 
The risk for schizophrenia for a co-twin of a schizophrenia patient 
is significantly higher (46 - 58%) for an identical (monozygotic) 
twin than for fraternal (dizygotic) twins (15%).  Adoption studies 
demonstrate that a shared genetic component, rather than shared 
familial environment, contributes to susceptibility for 
schizophrenia. Adoption studies indicate that adopted-away 
biological offspring of schizophrenia patients are also at 
heightened risk for schizophrenia.  These studies indicate that it's 
shared genes, not shared environments, that underlie the increased 
risk of schizophrenia in relatives of individuals with schizophrenia.
        Genes account for approximately 68 to 85% of the underlying 
risk for schizophrenia (McGuffin et al., l995).  The consensus is 
that genetic factors that cause schizophrenia are necessary but not 
sufficient for the development of schizophrenia.  One doesn't 
inherit schizophrenia; one inherits susceptibility to schizophrenia. 
Environmental risk factors are also important, and the genetic and 
environmental factors may interact.  Nearly all of the theories of 
the genetic basis of schizophrenia are based on what we call a 
diathesis-stress model.  In a diathesis-stress model there's a 
diathesis (or susceptibility) which is biological in nature.  The 
manifestation of that diathesis is triggered by a stressor, which may 
be environmental (pregnancy and birth complications, early 
childhood brain damage such as ischemic attacks/hypoxia, early 
exposure to viral agents, use of psychoactive substances such as 
cannabis or amphetamines, or psychosocial stress).  
        In a complex disorder such as schizophrenia, there are likely to 
be many genes that are involved in predisposing people to the 
disorder. The genes may affect brain development, they may affect 
neurotransmitter systems, or they may affect individuals at both 
these levels.  Investigators and theorists differ in terms of the 
number of genes that they believe are likely to be implicated in the 
underlying diathesis for schizophrenia. 
        While we can conclude that there's a strong genetic basis for 
schizophrenia, we have not yet identified the genes that are 
implicated.  We are hopeful that new molecular techniques and 
modern statistical analyses can allow us to focus in on particular 
genes that confer risk to schizophrenia.  The more genes that are 
associated with the disorder, the harder it will be to replicate 
associations between the disease and a given gene.  However the 
search for "schizophrenia risk genes" has been made more difficult 
by the fact that at present most researchers rely upon the presence 
of symptoms (disease phenotype) to identify individuals who are 
most likely to possess the genetic diathesis (genotype).  Indeed, 
progress in this area is stymied by the phenotypic heterogeneity of 
the disorder, i.e., the diversity in clinical presentation of the 
disorder, as well as the likely existence of etiological 
heterogeneity.  It remains very possible that there are different 
causes for schizophrenia, all of which can lead to the same 
outcome (Gooding & Iacono, l995).  

        The identification and use of heritable neurocognitive markers 
(known as endophenotypes; Gottesman & Gould, 2003) can be an 
invaluable aid in the genetic dissection of schizophrenia.  Here are 
characteristics of these biobehavioral markers of liability:  low 
prevalence among the normal population; genetic transmission; 
significantly higher proportion among affected individuals; 
stability over time; independence from clinical status (i.e., 
symptom remission vs. acute symptoms), and presence in 
unaffected relatives of affected individuals.
        There are several advantages to the application of 
endophenotypes to the search for the biological basis of 
schizophrenia. First, endophenotypes may assist genetic studies of 
schizophrenia because they can provide a way to identify 
individuals carrying the genetic risk.  Endophenotypes are believed 
to be closer in the etiological chain to underlying genetic factors 
than the symptoms of the disorder.  Moreover, endophenotypes 
have associated brain regions and circuits that may provide further 
clues about the areas that are dysfunctional in the schizophrenic 
        Examples of some promising markers of genetic liability for 
schizophrenia include:  oculomotor deficits such as smooth pursuit 
eye tracking dysfunction and saccadic inhibition deficits; working 
memory impairments; and sensory gating abnormalities such as 
P50 nonsuppression.  The occurrence of oculomotor impairments, 
such as smooth pursuit eye tracking abnormalities has been a 
consistent research finding since the l970s.  Individuals with 
schizophrenia have marked difficulty matching their eye velocity 
to the velocity of a slowly moving target, which results in 
abnormal smooth pursuit eye tracking.  Indeed during smooth 
pursuit eye tracking, individuals with schizophrenia show 
insufficient inhibition of small fast eye movements, which tends to 
take their eyes further away from the target they're trying to 
visually follow.  These deficits are observed in a disproportionate 
number of schizophrenic individuals even during their first episode 
of illness..  Some of my early work indicated that this abnormality 
is stable over time, regardless of chronicity, medication status, or 
clinical status.  Another potential marker of a schizophrenia 
liability is a deficit in antisaccade task performance, in which 
individuals are instructed to look immediately to the opposite side 
of a laterally displaced visual target. The neural basis of eye 
movements is well understood, so this remarkably consistent 
finding in individuals with schizophrenia and their first degree 
relatives (siblings, parents, and offspring) supports the notion that 
schizophrenia is a brain disorder.
        Working memory is defined as the ability to hold information 
in temporary storage, manipulate that information, and use it to 
guide subsequent behavior.  Spatial working memory impairments 
in schizophrenia were first demonstrated in the early l990s (Park & 
Holzman, l992).  Since then, several investigators have shown the 
following:  spatial working memory impairments in schizophrenia 
are common, they're seen in unaffected first-degree relatives such 
as parents and siblings, and they're stable over time.  
Schizophrenia patients have these deficits whether they're acutely 
psychotic or in remission, whether they're medicated or not, 
whether they're hospitalized or fully functioning in the 
        In the P50 paradigm, two auditory stimuli are presented in 
quick succession.  Normally, a person's neuronal response to the 
second stimulus will be smaller (lower amplitude) than the 
response to the first stimulus. P50 suppression is an indicator of 
information processing, or sensory gating.  Individuals with 
schizophrenia fail to show this P50 suppression.  Decreased P50 
inhibition is found in approx. 50% of patients and in 10% of 
healthy subjects.  P50 nonsuppression is also frequently observed 
in the first-degree relatives of schizophrenia patients.

Who is at risk for schizophrenia?
        There's increasing evidence that suggests that we may be able 
to identify the underlying diathesis, or viability to schizophrenia, 
before the risk condition progresses to full-blown schizophrenia. 
There are several ways of identifying individuals at heightened risk 
for the later manifestation of schiozphrenia: they can be identified 
on the basis of genetic, psychometric (questionnaire/inventory), 
biobehavioral, or clinical risk factors.  Much of the knowledge 
gleaned about the study of individuals at genetic risk for 
schizophrenia has been based on studies of the offspring of 
schizophrenia patient (Erlenmeyer-Kimling, 2000).  The presence 
of clinical risk factors can also be used to identify individuals at 
heightened risk for the development of schizophrenia.  One 
example of the clinical high-risk strategy would be to study 
individuals who have clinical disorders that are genetically related 
to, but less severe than schizophrenia, such as schizotypal 
personality disorder. 
        In the psychometric high-risk method, at-risk individuals are 
identified on the basis of their psychometric profiles using 
questionnaires or instruments such as the MMPI.  Much of my 
research at the University of Wisconsin-Madison focuses on 
elucidating the developmental trajectory from risk status to clinical 
disorder, whether schizophrenia, or a related, but less severe 
condition such as schizotypal personality disorder.  This is done by 
following at-risk individuals over time, and comparing them with 
typically-developing, age-matched individuals.  Using a set of 
well-validated instruments known as the Chapman psychosis-
proneness scales, investigators (Chapman et al., l994) observed 
that individuals who report the experience of strange perceptual 
experiences are at heightened risk for schizophrenia and other 
psychotic disorders such as psychotic mood disorders.  Individuals 
who report social anhedonia, or the reduced ability to experience 
pleasure and/or a deficit in the ability to seek and experience 
pleasurable activities, are at heightened risk for the specific 
development of schizophrenia and schizophrenia-related 
conditions (Gooding et al., 2005).  These findings are consistent 
with data from the genetic high-risk studies that indicate that 
attentional deviance in early childhood (a risk factor for the later 
development of schizophrenia) was associated with poor social 
skills, anhedonia in adolescence and social deficits in early 
adulthood (cf. Erlenmeyer-Kimling et al., 2000).  

Predicting the development of schizophrenia in at-risk individuals
        Studies indicate that offspring of schizophrenia patients who 
later develop schizophrenia and schizophrenia-related disorders 
displayed attentional deficits, verbal memory deficits and gross 
motor impairments even as children.  However, among the 
offspring of schizophrenic patients, only a subset of the at-risk 
individuals were later diagnosed with a schizophrenia-related 
illness. A composite index of risk was a better predictor of a 
schizophrenia-related outcome than reliance upon a single 
indication of deviance.  Because not all good predictors of 
schizophrenia outcome, such as lower IQ or motor impairments, 
are indicators of a genetic liability towards schizophrenia, 
searching for the presence of the endophenotypes in the genetically 
at-risk population is especially beneficial. At present, we cannot 
predict who, among the individuals at risk for schizophrenia, will 
later manifest the disorder or one of its spectrum disorders, such as 
schizotypal personality disorder, or schizoaffective disorder. 

Can we intervene in the case of at-risk individuals before they 
develop psychotic symptoms?
        A newer research strategy concerns the study of individuals at 
the prodromal stages of schizophrenia, before they have an 
outbreak of manifest psychosis.  So clinical researchers attempt to 
treat individuals who are showing functional deficits like those 
seen in schizophrenia, but who are not yet experiencing the 
psychotic symptoms of delusions and hallucinations.  This research 
strategy is based on the premise that the premorbid and prodromal 
phases of schizophrenia are windows of opportunity to intervene, 
in order to maximize the likelihood of a better disease outcome. 
These early intervention programs are preventive in the sense that 
part of the goal is to prevent further psychosocial decline, and/or to 
delay the onset of severe psychosis. The risks and benefits of these 
early intervention programs are currently investigated and debated.  
The preventive treatment of individuals who show an accumulation 
of risk factors is based upon a statistical risk-oriented approach to 
treatment.  The study of biologically-based markers, in conjunction 
with other screens, e.g. clinical signs and behavioral symptoms, 
can be useful in terms of further identifying who the target 
population should be, which risk factors are most valid as 
screening tools for the entry into the study, and what prodromal 
deficits should be targets for intervention.  Endophenotypes are 
increasingly being integrated into some of these prodromal studies.

Current status of schizophrenia research
        The consensus is that schizophrenia is a genetically-mediated 
neurodevelopmental disease that is typically developed during late 
adolescence and early adulthood.  We don't know which genes are 
involved, how many need to be present, and how they affect brain 
        Schizophrenia is associated with neurobehavioral impairments.  
We know that as a group, people with schizophrenia differ from 
healthy people in terms of neurocognitive and psychophysiological 
performance.  A disproportionate number of biological relatives of 
schizophrenia patients also display these deficits, albeit to a lesser 
degree.  Research indicates that these biobehavioral deficits are 
stable over time.  We can conclude that several of these 
neurocognitive impairments are potential markers of increased 
susceptibility of risk for schizophrenia.  The study of these putative 
markers can be useful in terms of refining the diagnosis and 
classification of schizophrenia and schizophrenia-related disorders.  
These markers also have the potential to enhance our current 
research strategies for identifying individuals at heightened risk for 
schizophrenia.  We know that not everyone at heightened risk for 
schizophrenia goes on to develop the disorder. However, it appears 
that even prior to the onset of the disorder, individuals who later 
develop schizophrenia deviate on a range of functions, including 
attention and information processing, motor development, 
language difficulties, and social behavior.  We don't know how 
schizophrenia develops from risk to manifest disorder.  We are at 
the very beginning of discerning the ways in which the at-risk 
individuals who later develop schizophrenia differ from those at-
risk individuals who remain clinically compensated. We are still 
investigating whether indicators and predictors which have validity  
at the population level have predictive validity at the individual 
level as well.  Prodromal studies of schizophrenia are underway.

        My hope is that the scientific community will have adequate 
resources to continue the research, so that can we further the 
progress of unlocking this epigenetic puzzle that we call 
schizophrenia.  I'm proud of the work that we are doing in 
Wisconsin to help demonstrate the ways in which schizophrenia is 
a genetically-mediated neurodevelopmental disorder.  At the 
University of Wisconsin, many of the researchers like myself have 
partnered with mental health professionals, mental health 
consumer organizations and community advocates such as NAMI 
(which originated in Madison, WI) to educate the local community 
as well as the community at large about schizophrenia.  It is 
especially gratifying to participate in dispelling myths and 
correcting misconceptions about schizophrenia and schizophrenia-
related disorders through education, research, and advocacy.
        Thank you for the opportunity to offer testimony on this 
important health issue.  At this time, I would be happy to answer 
any questions.

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McGuffin, P., Owen, M.J., & Farmer, A. E.  (l995).  Genetic basis 
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        MR. DEAL.  Thank you very much.  
        I will begin questions.  
        You have talked about these markers of genetic liability.  Did 
you call them endophenotypes?  
        DR. GOODING.  Endophenotypes, and they are closer in the 
chain, the causal chain, than phenotypes which are the clinical 
manifestations, the symptoms of a disorder.  
        MR. DEAL.  Would the same general statements about these 
markers apply to other disorders other than schizophrenia?  
        Dr. DePaulo, you are indicating yes?  
        DR. DEPAULO.  Absolutely.  But they are better known in 
schizophrenia than they are in depression or bipolar disorder.  So 
they are very helpful.  
        MR. DEAL.  Dr. Insel, are we further along in any of these three 
general areas we are talking about in terms of research?  Since we 
have talked about schizophrenia, are we further along in the 
research for that disease than we are for the bipolar or just simple 
        DR. INSEL.  Yes, I think we are.  It is surprising.  If one had 
looked at this 20 years ago, one would expect that all of the big 
breakthroughs in genetics and in the biology would have involved 
bipolar disorder, and Dr. DePaulo has been at the cutting edge of 
that science.  But much to our surprise, it is in the area of 
schizophrenia where we have found the greatest association 
between genetic variation and having the disease or being, as 
Dr. Gooding mentioned, at risk for the disease.  So, right now, 
schizophrenia is the place where I would say there is the most 
traction and the most excitement.  
        MR. DEAL.  We have made the analogies to cancer in several 
different comments that have been made.  When we think of 
cancer and the treatment for it, we normally think of surgically 
removing it or treating it chemically to shrink the cancer, or 
perhaps eliminate it altogether.  I gather we are not able to make 
that same analogy in terms of the treatment of these mental 
diseases.  Can you surgically remove something that would 
eliminate any of them?  Can you chemically treat them to make it 
disappear or simply try to overcome what is there?  
        DR. INSEL.  The question really comes down to, can we go 
from response to cure?  And that is true in the case of cancer and 
heart disease; we have set the goal at cure.  And that is particularly 
true of diabetes, where one looks for what is going to be the cure.  
        Increasingly in medicine generally, we are having to settle for 
being able to help people with the chronic illness to be able to live 
better lives, what we call more recovery than cure.  The cure is not 
yet in sight for most of these disorders, but there are opportunities 
to reach for recovery, and more than we have had in the past.  
Some are medical, and some are actually psychosocial treatments.  
        In the case of schizophrenia, we know that some of the 
treatments, some of the interventions that make the greatest 
difference are not necessarily medications, although those are 
necessary.  It is helping people with this chronic illness to be able 
to live with it, to be able to live in a community where people are 
supportive.  Getting families involved and getting them back to 
work, is really essential.  
        MR. DEAL.  Anyone else?  
        DR. GOODING.  I would like to add that there used to be the 
myth that if you got the diagnosis of schizophrenia, it was 
tantamount to a death sentence or the prognosis was very poor.  
We do have better treatments, and as Dr. Insel said, right now, we 
are concentrating on helping people really further integrate into the 
        We have a program that started actually in Madison, 
Wisconsin, the PACT program, Program for Assertive Community 
Treatment, that really worked towards bringing the focus of 
treatment outside of the hospital into the community.  It is a 
community-based multidisciplinary treatment strategy.  
        They leave patients where they are, and they help them get into 
the workforce, live independently, and really move toward 
recovery and self-actualization so it is really gratifying to see the 
improvements and be able to tell people, you have been diagnosed 
with this chronic disorder, but here are the things you can still do 
and here are the ways we are going to help you get there.  
Including psychosocial interventions, social skills training, and so 
        DR. DEPAULO.  One last point, in the analogy of cancer, it was 
the appearance at the macroscopic level, at the eyeball level, of 
tumors that led to the recognition that surgery might be helpful.  
But from the research in the molecular biology of cancer have 
come treatment strategies that we never imagined, such as 
treatment strategies designed through hormones, through the 
immune system, and through the blood supply to cancers.  
        Those are the kinds of treatments that you can't imagine yet 
that we hope to come up with to aid all of these other treatments in 
schizophrenia, bipolar disorder, and depression.  
        MR. DEAL.  Thank you.  
        Ms. Baldwin.  
        MS. BALDWIN.  Thank you, Mr. Chairman.  
        I would like to hear a little bit more about the impact of recent 
cuts or flat funding of NIH with regard to the research.  As you 
heard me proudly say in my opening statement, I represent the 
University of Wisconsin, Madison, which receives a great deal of 
support for biomedical research through NIH funding, and I have 
been hearing anecdotally from researchers on campus about the 
impact of recent flat funding in terms of grants cut short or 
experiencing their colleagues with very high-quality grant 
applications which are being denied at a much higher rate.  No 
doubt these are because of Congressional action in funding the 
NIH in recent years.  I know in the past 4 years, we have not kept 
pace with medical inflation, which is around 3.5 percent, meaning 
the cost of doing research is increasing, but the funding available 
for the research is either flat funded or cut.  
        I am wondering if any of our researchers here today have felt 
the effects of these policies, and has it affected your own research 
or the research of your colleagues?  And additionally, how is it 
affecting recruitment of new talent, new investigators into the 
        DR. DEPAULO.  As a chairman of a department that has 180 
faculty members, I would be happy to tell you, because the results 
are palpable and very visible.  
        To the point, my faculty has been extraordinarily stable across 
the years.  When people come onto the faculty at Hopkins, they 
tend to die on the faculty, much later, thankfully, and after very 
successful careers.  But recently, in the last year and a half, we 
have been losing young very talented investigators, actually 
several of them funded by the NIH, because they can see the 
handwriting on the wall, as they put it, and they are going to places 
that don't offer them the same kind of scientific opportunities, but 
where they are sure of being funded.  I am very concerned about 
the loss of a generation of young, very talented investigators.  
        DR. JAMISON.  I couldn't agree more, and I think it is such an 
exciting time in neuroscience.  All of us have lived with so much 
hype and promise for so long, and now in the last 10 years, it really 
has begun to take off.  It seems the oddest, most strange, and 
devastating time to cut back.  It really will affect tens of thousands 
of lives.  There is no question about it.  
        DR. GOODING.  I can say that personally I have been the 
beneficiary of NIH grant funding, and it was invaluable in terms of 
being able to investigate the risk factors and to follow 
longitudinally people at hypothetical risk for schizophrenia.  We 
found some really exciting things, and we would not have been 
able to do it otherwise with the cuts in funding or at least the flat 
        We have more ideas from some of my colleagues in my 
research lab, and it is really difficult because they are saying, yes, 
this is a great idea and it would be very helpful in terms of 
furthering the field.  But you know what, in order to get NIH 
funding right now, you are going to need a lot of pilot data.  How 
do you get the pilot data if you don't have the funding?  So it is 
very frustrating.
        DR. INSEL.  I feel the pain from our side.  As you mentioned, 
the biomedical inflation rate is somewhere between 3.5 and 4 
percent.  That is part of our challenge.  Although we have a 
doubling since 1998, we are funding more grants, and the grants 
are larger than they were.  We still are able to do quite a bit of 
great science, but this has been a time where we have had to set 
        The reality is that the Nation, this Nation, invests about $4.76 
per American for research on mental illness each year.  And we 
have to ask not whether this is a cost center, but whether this 
investment is the right investment for the level of concern that you 
have heard this morning.  
        MS. BALDWIN.  Thank you.  
        Thank you, Mr. Chairman.  
        MR. DEAL.  Thank you.  
        Ms. Myrick.  
        MS. MYRICK.  Thank you, Mr. Chairman.  
        Dr. Jamison, I know you have done so much research and are 
an expert on suicide, and I want to ask you a question and also 
make a comment because we have talked about the people who 
have the illness committing suicide themselves.  
        Recently, in our community, we have had two fathers, living in 
great neighborhoods, great careers, everything about them very 
normal, one of them who actually was successful in killing two of 
his own children.  He did not take his own life.  The other one tried 
to kill both of his young children.  One is still living, but he took 
his own life.  
        I share that because that is another aspect of this that we don't 
talk about, not just taking their own life but taking someone else's 
life as well.  
        Do you know what percentage of bipolar people actually do 
end up committing suicide, because I know a lot attempt it?  Our 
granddaughter attempted it several times, thankfully 
unsuccessfully.  But any percentages on that?  
        DR. JAMISON.  There are percentages depending on how 
serious the form of bipolar illness is.  If you take people who have 
been hospitalized for bipolar illness, the rate of suicide goes up 
somewhere between 15 and 20 percent, which is a higher mortality 
rate than most forms of cancer or heart disease.  I think one of the 
unfortunate things about psychology and psychiatry is that, as a 
profession, we have not used the words "mortality rate" when it 
comes to our own illnesses.  So there is this notion that suicide is 
off in the ether and it is caused by stress or things that go on in the 
environment as opposed to 90 to 95 percent of the time being 
associated with a major psychiatric disorder.  
        We have done ourselves a big disservice by not focusing on 
how very strongly associated, and of the illnesses, major 
psychiatric illnesses, certainly bipolar disorder has the highest 
suicide rate.  It is a very real concern.  
        MS. MYRICK.  Dr. Insel, I was glad to hear you talk about 
personalized care for these diseases just like we have done for 
cancer.  That is really exciting.  And yes, I know funding is a 
problem for that, but that is something that is good on the horizon 
where we haven't been before.  
        Either you or Dr. DePaulo, you introduced me to the term of 
presenteeism some time ago, people who are actually present at 
work but don't do anything.  Would you both elaborate on that, 
because I think that is something that we totally overlook in 
society?  We talk about people who are absent from work because 
they have problems.  What about the people who actually show up 
for work but don't do it?  
        DR. DEPAULO.  Since depression is probably one of the most 
common sources of that kind of lost productivity, what you find 
from your patients is that, one is, first off, when they are depressed, 
depression is not simply feeling sad when your dog dies, people 
have multiple inabilities to function.  Concentration and attention 
is certainly one of the things hit quickly and hard by depression.  
        The second thing that happens is the idea that even having an 
interaction with somebody, going to see a client, going to interact 
with other workers to get something done, becomes a big stress for 
people, and so they tend to avoid doing that, and they tend to be 
more irritable.  So people, when they are depressed, although most 
are in the workforce and about 80 percent are working.  They are 
unable to concentrate, they tend to withdraw a bit because they are 
irritable, and they don't have the energy to sustain the interaction 
to get the job done.  
        DR. JAMISON.  And they are also more likely to use alcohol and 
drugs which then compounds all of the problems.  
        MS. MYRICK.  There is an article in the Wall Street Journal 
today that says, a study that says heart troubles often lead to 
depression, and it is talking about people who are depressed who 
have heart attacks, and I thought it was very interesting.  
        On the schizophrenia side, Dr. Gooding, this is an area that I 
don't understand very well.  I read through your testimony, and so 
much of it is over my head, and forgive me.  When you talked 
about the multiple personality disorder and schizophrenia and how 
that is confused, can you address that a little bit?  
        DR. GOODING.  That is a common misconception.  Multiple 
personality disorder, which now is called dissociative identify 
disorder, has to do with different personality states, different 
memories and one aspect of the personality not knowing or having 
awareness of other aspects of personality.  That is very different 
from schizophrenia.  
        Schizophrenia is really a cognitive disorder in which there is 
some exaggeration of some functions, such as delusions, false 
beliefs, hallucinations on the one hand, and that is what most 
people think about when they think about schizophrenia.  But more 
devastating for people with schizophrenia are the negative 
symptoms, the symptoms that represent loss or diminution of 
functioning and those are things like loss or lack of motivation; 
anhedonia, loss of pleasure; reduced speech; reduced 
expressiveness, facially, and emotionally.  As you can see, it is 
very different.  One is clearly a psychotic disorder.  Where there is 
lots of evidence for genetic basis in dissociative identify disorder, 
there is still a bit of controversy regarding the rates of diagnosis 
and the validity of it.  
        MS. MYRICK.  Mr. Chairman, if I may, our colleague, Patrick 
Kennedy, was here for a while and had to leave, but I just wanted 
to take this opportunity to thank him about being open about his 
challenges because that is a big help to everybody.  
        Thank you.
        MR. DEAL.  Thank you.  
        Mr. Rush is recognized for questions.  
        MR. RUSH.  Dr. Insel, can you tell me, can you tell what the 
NIMH is doing with regard to research on postpartum depression 
and psychosis?  
        DR. INSEL.  There is a broad range of studies that are looking at 
both the mechanisms and the best treatment for women during this 
        It is a complicated area because there are many different 
syndromes that fall under the umbrella of postpartum depression, 
and postpartum psychosis sometimes overlaps with that, and 
sometimes is quite different.  
        There is no question that in some way it relates to the 
endocrine changes that accompany the end of pregnancy.  But we 
still don't understand the mechanism by which that group, that 
profile of endocrine changes, puts women at risk.  We do know 
that the risk is huge, and women at that point in life, especially if 
they have a history of depression, are many, many times more 
likely to develop a severe depression at a moment when their 
energy and attention is more vital than at any other time to their 
        So it is an area of high priority for our institute where we hope 
to be able to have some real discoveries very soon.  
        MR. RUSH.  Do you have any opinion about the way in which it 
is being viewed or the way that it is being portrayed or not 
portrayed as far as our legal system is concerned?  
        DR. INSEL.  I am not sure what your concern is?  
        MR. RUSH.  There seems to be a strong reluctance by the 
judicial system to even entertain the possibility that postpartum 
psychosis is a mental illness, and therefore, those unfortunate 
victims find themselves in positions where they are denied really 
the full weight, I would say denied a fair trial.  
        DR. INSEL.  Science would certainly support the idea that this 
form of depression, or psychosis, either one of them, are brain 
disorders, just as other forms of major depressive disorder and 
other psychotic illnesses.  We have that kind of evidence, and we 
also know they are treatable.  
        But as we have been saying all morning, one of the gaps we are 
facing here is that we have the science on the one side, which often 
doesn't match up perfectly with public policy.  Part of the 
challenge is making sure that science informs service at some 
        MR. RUSH.  Any other comments?  
        DR. JAMISON.  I think, in general, there is a huge gap between 
what many judges know about mental illness, and I was actually 
talking to a friend of mine who is an attorney and asking him what 
kinds of courses were taught in law school.  Given so much of the 
law relates to human behavior and abnormal human behavior, what 
kinds of courses are actually taught about psychopathology and the 
science of psychopathology?  Next to none, which to me was 
staggering because we all know the cases that have come before 
the courts with postpartum psychosis where a mother has killed 
one or more children and how dreadful that is and how preventable 
often it is.  
        What strikes me is that highly educated lawyers know very 
little about psychopathology despite the fact that the ones in the 
criminal system deal with it all the time.  
        MR. RUSH.  I have given you an example.  I have a bill that is 
pending in the Congress that is called the Melanie Blocker-Stokes 
Postpartum Depression Act.  Melanie Blocker-Stokes she was a 
young African-American woman, professional, came from an 
upper middle class family, was a sales manager for a leading 
pharmaceutical company.  She married a physician.  She had a 
disease.  Nobody knew what it was, and she committed suicide.  
She jumped out of a tenth floor hotel window on a bright Saturday 
afternoon and left one child.  Her husband was a physician, and he 
had no understanding.  He had never heard of a postpartum 
depression, and so the medical profession is also ignorant about 
this.  I think it probably has a lot to do with the fact that it affects 
women, and there is a disparity in terms of concern about women's 
        I am just astounded that even Members of Congress, when I 
went to get cosponsors on the bill invariably, out of all of the 
people I talked to, probably a third of them had some experience 
with somebody who had postpartum psychosis, but we still have 
not been forward in our solutions or our attempts to deal with this 
particular issue.  
        Mr. Chairman, I yield back the balance of my time and will 
have some additional questions if we do a second round.  
        MR. DEAL.  I thank the gentleman.  
        Dr. Burgess.  
        MR. BURGESS.  Thank you, Mr. Chairman.  I apologize for 
being out of the room for most of the testimony.  
        Dr. Insel, it comes to mind, hearing your response to questions 
from others on the committee, just as an outsider looking in, and I 
have only been here a short period of time, but as an outsider 
looking in, I can't help but feel there is a lot of duplication, for 
want of a better word, when you look at the various institutes, 
National Institutes of Health, National Institute of Mental Health, 
National Institute on Alcohol Abuse and Alcoholism, and run 
through the list. 
        MR. BURGESS.  Has that been at all an encumbrance upon the 
correct application of research dollars as you see it?  
        DR. INSEL.  Well, as I think you have heard from NIH Director 
Zerhouni when he has testified here, there has been a huge, new 
thrust to try to coordinate all of the Institutes around projects like 
the NIH RoadMap which are across Institutes and involve an 
integrated and shared approach to the biggest impediments of 
medical science.  I might add that, because of the Institutes that 
you've mentioned, in the last 2 years the groups that are interested 
particularly in the brain and mental disorders and drug abuse have 
also developed their own integrated effort which is called the 
Neuroscience Blueprint.  That is actually very much like the 
roadmap in which, rather than having redundancy and duplication, 
we are actually bringing the best from all of those Institutes 
together to try to address common problems.  And there are many 
common problems, because we are all ultimately dealing with the 
central nervous system.  But we come at it either through the eye 
or the ear or, in our case, through abnormal behavior, but we have 
this opportunity now to do this in a very integrated way, and I 
think it is working very well. 
        MR. BURGESS.  Is that in a form where it can be shared with 
Members of Congress at this point, the Neuroscience Blueprint?  
        DR. INSEL.  Absolutely, I would be happy to submit that for the 
record.  We are in our second year.  We have a very active Web 
site.  We have 15 or so projects already funded and maybe more 
than that, and we can get you up to date on all those issues. 
        MR. BURGESS.  I will leave it up to the Chairman whether or 
not he wants it in the record, but I know my office would very 
much appreciate being informed of that because you are correct, 
Dr. Zerhouni, in his own inimitable way, implied that perhaps 
Congress shouldn't be interfering with the make-up, but he also 
acknowledged that there was, at least to the uninitiated outsider, he 
could understand how the appearance of duplication of services 
might lead one to believe that perhaps it is not the best or most 
efficient application of research dollars. 
        In your written testimony, talking about the new things that are 
going on between understanding of the human genome and 
neuroscience, it actually sounds pretty exciting.  Can you give us 
any specifics to things that you are working on in particular there?  
        DR. INSEL.  Very quickly, as we were mentioning before, I 
think the greatest traction happens to be right now in schizophrenia 
where we have a whole range; I think there are eight or ten 
candidate genes where there seems to be an association between 
variation in a particular gene sequence and risk for the disorder. 
        But hands down, the most exciting opportunity now is what is 
called whole genome association, and that has been made possible 
by something called the haplotype map.  This is a map of human 
variation at the genetic level, so it is a map of where all the most 
common variants are in the human genome.  It offers the 
opportunity to scan those very, very quickly in a way that we never 
imagined possible 5 years ago, quickly and cheaply.  All of this has 
really come about in the last 6 months, the whole human genome 
hap map will be available later this year, but we have a very good 
working draft that has already had a tremendous impact on a whole 
range of disorders.  We expect that will affect the way we look at 
variation and the molecular basis of risk in mental disorders as 
        MR. BURGESS.  And do you see a date on the horizon where 
that will be generally available to the clinician?  
        DR. INSEL.  Well, the big challenge, Dr. Burgess, is how you 
go from having an exegetic research finding that explains, say, 
5 percent or 3 percent of the risk, to being able to take that and 
make a difference for clinicians.  Where I think it will come first is 
not actually in the diagnosis of any of these disorders but in the 
selection of treatments. 
        So we already have evidence that has just come out in the last 
6 weeks that we can predict who is more or less likely to respond 
to a serotonin reuptake inhibitor treatment for depression, and I 
think we will have a number of those genetic variants that tell us 
about medication response.  As you know, we call that 
pharmacogenomics, and I think that is going to be the first 
deliverable to happen very quickly.  
        MR. BURGESS.  It is no secret that in my mind at least managed 
care is not the thing for the practice of psychiatry in this country. 
        But one of the unintended consequences was for someone like 
myself who is in more of a primary care field, OB/GYN, by 
default, I became the prescribing physician for antidepressants, and 
I can't tell you how excited I am to hear you talk about that 
because, so often, I was left with my best clinical judgment as to 
which of this wide panoply of antidepressant medications might be 
the best one for this particular patient.  And probably about 
80 percent of the time, I was satisfied with the result.  But about 
20 percent of the time, I was not only unsatisfied with the result, I 
was struck by how wrong I could have been on the selection of a 
particular agent for a particular patient.  So that just, from the 
perspective of a practicing physician who had the practice of 
psychiatry forced upon him by external forces in the insurance 
world, I am very glad to hear you talk about that because I think it 
is going to make us much more effective in our ability to deliver 
care for patients. 
        Now, Mr. Rush, who has I guess already left, talked a little bit 
about postpartum psychosis and unfortunately probably using 
depression and psychosis interchangeably there where it is not 
actually well suited for that interchangeability.  But you talk about, 
in the imaging part of your discussion on area 25, sounds like 
where they took the alien from Roswell, but nevertheless, area 25 
in the brain that has some specifics to it, have you looked into the 
management of postpartum psychosis with these imaging 
        DR. INSEL.  That is a great question and the answer is, no, that 
study hasn't been done, recognizing that much of this research has 
really just emerged in the last 9 to 12 months.  Much of it is still 
underway, so there is a lot of interest in moving forward with those 
kinds of studies for postpartum depression, but it has not yet been 
done as far as I know. 
        MR. BURGESS.  Again, he alluded to the difficulty with the 
disease being much more common than people think, and yet, at 
the same time, even the unfortunate individual who was a 
physician and married to a patient didn't recognize the signs, and I 
will tell you, as a physician who is also a husband, it is sometimes 
difficult to recognize signs, not just postpartum depression but 
from other more common illnesses.  I think I missed the diagnosis 
of chicken pox with all three children.  We don't need to put that in 
the record, Mr. Chairman. 
        MR. DEAL.  It is there forever.
        MR. BURGESS.  But a tool like this would be so helpful, and 
you know, during the course of the day, the average OB/GYN who 
sees what 30 to 45 patients in order to pay overhead and liability 
insurance and has to make a decision based on a 10- or a 
15-minute interview with a patient who is struggling after delivery, 
to know which ones are truly at risk.  And, unfortunately, as we 
have seen in Texas, some very famous and very dramatic cases of 
postpartum psychosis that resulted in the injury to in some cases 
multiple children within a family, the ability to be able to provide 
that practitioner with a reliable test that would be 
community-based or nearby in a community to be able to say, I 
need to send you down to the Medical School to get this scan done 
because I am concerned about your symptoms, that would be 
tremendous to be able to put that in the hands of practicing 
physicians across the country.  
        With that, Mr. Chairman, you have been very indulgent, and I 
will yield back.
        MR. DEAL.  I think Dr. Insel wanted to respond.  
        DR. INSEL.  The NIH mantra now is what we call the three Ps, 
that is:  predictive, personalized, and preventive.  And I think all of 
those together, if we can deliver that to individual practitioners, is 
where we want to be. 
        MR. BURGESS.  Mr. Chairman, just a point of personal 
privileges, coming to Congress, I did not realize what a national 
treasure the NIH was. 
        I have taken now a series of field trips out to a variety of the 
institutes out there.  Every time I do that, I come back so impressed 
with what is going on and so optimistic about the future of our 
country and what we are going to be leaving for our children, 
because you guys are doing work out there that is nothing short of 
fantastic.  I will yield back. 
        MR. DEAL.  Thank you.  
        Mr. Pickering you are recognized for questions. 
MR. PICKERING.  Thank you, Mr. Chairman, I want to thank the 
panel, and I want to thank the Congresswoman from North 
Carolina for her leadership.  It was great to hear a physician on the 
committee, Dr. Burgess, as he engages.  And it is truly remarkable 
the progress that we have made in understanding mental illnesses.  
And as Congresswoman Myrick has appropriately defined various 
brain diseases.  
        I would like to ask Dr. Insel what we have seen over the last 
10 years, what would you say you see over the next 5 to 10 years 
in our understanding, our ability to do the three Ps, to be able to 
predict whether a child born next year could be susceptible to 
autism-related disorders or to mental illnesses, bipolar, mental 
depression, and to what degree will we be able to give those 
therapeutic predictors or plans and help to our physicians and our 
psychiatrists and psychologists, and to our families?  And to what 
degree will the pharmacological prescriptions be enhanced to 
really make a difference in the lives of a lot of individuals and 
families?  So what do you see over the next 5 to 10 years?  
        DR. INSEL.  Well, it is a tall order.  Let me just give you the 
10-second overview which is that the three Ps will come about 
largely with the two best tools we have now which are genomics 
and imaging.  And you can probably add to that some better kinds 
of neurocognitive batteries, as Dr. Gooding was talking about for 
schizophrenia.  We have already seen this with autism, although 
we don't have the genetics yet, and imaging hasn't been 
particularly informative.  With some of the neurocognitive tools, 
we have taken the diagnosis of autism from a point much earlier 
from 5 years ago, when most children were being diagnosed at age 
4, 5, or 6, depending on their level of access; we are now able to 
reliably diagnose autism well before age 3 and, in some cases, 
before age 2.  And that is critical, because we know that if we can 
intervene early, that we can, in some cases, preempt many of the 
worst aspects of this very devastating illness.  
        I wish I could say we could now do the same thing for 
schizophrenia.  We are not quite there.  But there is no question 
that through the use of genetics, through imaging and through all 
of these other kinds of tools like neurocognitive batteries, the 
vision for mental disorders is very much the vision that we have 
had for cardiology and cancer.  For example, for schizophrenia, we 
want to be able to intervene well before the first break, just as with 
heart disease, we now intervene generally before the first heart 
attack.  And so much of what cardiology is about now is 
preemption; it is treating people with lifestyle changes, with diet 
and sometimes with statins to keep them from having a heart 
        We need to be taking just that pathway forward for 
schizophrenia, for bipolar disorder, and for autism. 
        MR. PICKERING.  Anybody else on the panel like to--and what 
policies can we adopt to help accelerate, if Dr. Burgess was talking 
about getting the scanning and the imaging capabilities out to the 
physicians and to the community, what are the things that this 
committee can do, both in research, and in practical resources to 
the communities, hospitals, physicians, that would accelerate that?  
        DR. DEPAULO.  Well, if I might and I will say that we all have 
the dream that we are going to be able to, quote, "translate a basic 
science finding into a deliverable treatment," and so far, those 
things still take years to do. 
        So that is why I think that the war on cancer and the serious 
work that is being done on heart disease is, I consider, about half 
        But I think one of the things you can do is to obviously not 
only increase funding for research but to make it predictable, so 
that it won't be varying up and down so much.  That would be very 
helpful I believe, and I think Dr. Insel would possibly be very 
much happier if he could plan ahead beyond the life of a particular 
grant.  I think that is also extremely important, as we were saying 
earlier, for the careers, because we don't just need money.  We 
need young careers of people who are going to devote their lives 
and their careers to this.  You don't want to cut off a generation of 
those people, so certainly those are two ideas.  
        I think in terms of translating, I think we need a number of 
things to happen on the clinical side, but certainly I don't want to 
neglect the idea of public education.  I still think that is 
fundamentally important, and when people know what they have, 
they become much better in some ways.  Coming from Dr. 
Burgess, is that we find that it is easier to educate patients 
sometimes than it is to educate physicians who weren't trained at a 
time in which a certain development took place. 
        So those are certainly points I would make. 
        DR. JAMISON.  One of the things that is always striking to me 
is, parents learn about mondo bizzaro diseases that kids never get 
that are very rare diseases, and they learn next to nothing about 
depression and bipolar illness, which are very common illnesses.  
It seems to me that pediatricians and doctors who are primary care 
physicians have an obligation to not only learn themselves but also 
to transmit that education through the school systems.  One of the 
things that is great, Johns Hopkins for example has a very 
aggressive program in the Baltimore public and private schools to 
educate kids, teachers, and parents about depression.  I just think 
this should be much more common than it is.  There is one thing 
that you can do in terms of research that is going to affect people 
10 years from now; what can you do to keep people alive now with 
what we do know?  
        DR. GOODING.  I would like to echo that and say that education 
is so critical, increasing public awareness, not just about mental 
illness in general but about specific warning signs or specific 
help-seeking or specific behaviors that would lend one's self to 
realize that maybe they should start seeking help. 
        We also need to educate people.  They need to know that there 
are more advances now in terms of mental health treatment and 
mental health research.  So that they don't feel that there is no hope 
and that they do go and follow up on the treatment 
        Furthermore, we need to educate people so that we can reduce 
stigma because people are not going to go and admit to having 
problems and they are not going to seek treatment if there is stigma 
associated with doing so. 
        MR. PICKERING.  Mr. Chairman, thank you.  
        And I would be interested to follow up just on how much we 
are spending on the educational side of educating and informing 
the public, but I know my time is up. 
        MR. DEAL.  Thank the gentleman and to the panel, very 
excellent testimony, and any documents that you wish to submit 
for the record, Dr. Insel, one of the references to the question from 
Dr. Burgess about that study would be certainly appreciated, and 
we will, without objection, allow that to be included in the record. 
        [The information follows:]

        MR. DEAL.  I want to thank the panel very much for your 
distinguished testimony. 
        Now I call the second panel to the table. 
        MR. RUSH.  Mr. Chairman, I would like to ask unanimous 
consent--there were questions I had of the first panel.  I am sorry I 
was out on the phone, but I would like to submit the questions in 
writing so I might be able to get--
        MR. DEAL.  Yes, I have already done a unanimous consent that 
would allow any member to do that, and certainly, I think they 
would be willing to respond to your questions. 
        MR. RUSH.  Thank you Mr. Chairman.  
        MR. DEAL.  Likewise, we have a second distinguished panel.  
We want to thank all of you for being here.  It is my pleasure to 
introduce them at this time. 

        MR. DEAL.  Jennifer Martin is an attorney who is in private 
practice in Topeka, Kansas.  She is here today to talk about her 
struggle with severe depression and her efforts to treat her 
        Mr. Gil Lamphere is a capital fund manager.  Mr. Lamphere 
has a very distinguished business record, having worked at Morgan 
and Stanley as a Vice President and many other areas of the 
business world, and, in 1998, founded Lamphere Capital 
Management where he is the Managing Director.  
        And Peter Earley, who is a journalist and author, a New York 
Times best-selling author and a former reporter at the Washington 
Post.  We are pleased to have him here today, and he is going to 
talk about his son's mental illness and the family's experience in 
dealing with bipolar disorder.  
        We are pleased to have all of you, and I will say to you as I did 
the first panel, your written testimony is in the record, and we 
would ask you if you would to use your minutes please to 
summarize that and talk about issues that are of concern with you.  
Thank you.  
        We will begin with Ms. Martin.
        MS. MARTIN.  Thank you, Mr. Chairman Deal.  I want to thank 
the Chair and the members of the committee and especially 
Congresswoman Myrick for holding this hearing today and 
allowing me to testify on this vitally important issue.  
        If anyone had told me 5 years ago that I would be sitting here 
testifying in front of the House of Representatives about my own 
mental illness, I would have told you that you were crazy and that, 
certainly, I wasn't crazy, and I was never going to be crazy. 
        I grew up in the Midwest, outside of St. Louis in a normal 
every day average household.  I have the same parents I started 
with.  We had a dog and a picket fence. 
        Life was perfect.  But inside, inside the family, I knew of 
depression.  My Mom had suffered from depression, from 
postpartum depression and generalized major depressive disorder 
her whole life, it was always untreated and only once diagnosed.  
Her sister, my aunt, committed suicide in 1987 from diagnosed but 
untreated bipolar disorder.  So it was always the specter in my 
family.  I had bouts of depression, the blues, things like that, but I 
thought that was normal because, in my family, everybody 
suffered from depression that was undiagnosed, so that was my 
normal life.  
        I sort of thought, once I grew up and got out on my own and 
had my job and had my life, I would be happy, and things would 
be fine. 
        So I kind of pushed aside those empty feelings or the bad 
feelings I had.  I graduated from the University of Missouri Kansas 
City School of Law in the top of my class.  
        I was recruited by the two largest most prestigious firms in 
Kansas City, went to one of them and had what everyone thought 
was the perfect life.  I made great money.  I had good friends.  I 
had the perfect job.  I had a perfect life, but I was absolutely 
miserable.  The fact that everyone kept telling me, oh my gosh, 
you must be so happy with yourself, and life is great, made it 
worse.  I would go home and sit by myself and be miserable on a 
daily basis. 
        We talked over and over today about stigma and the stigma of 
mental illness.  When I first started working at the law firm, I was 
told, don't let them see you sweat.  Don't let them know that you 
are stressed because they will think you can't handle the work.  So 
I was able to push those feelings down, but then I had to be there.  
I had to make billable hours.  I had to work 7 days a week, and I 
didn't have any recovery time.  Partners kept asking me, what is 
going on, you are not meeting your billable hour requirements?  It 
was like I had a secret life.  During the day, I was a hot shot young 
associate, and then, at night, I was binge drinking and using drugs 
in an effort to mask the pain and mask the depression that I felt. 
        I can't even explain what it is like to live that secret life, for 
people to say, oh, you have a perfect life and everything is rosy, 
and then to be doing cocaine on the weekends and waking up from 
a bender and not knowing what had happened the weekend before. 
        I was really sick, but I couldn't tell anybody because of the 
stigma that was associated with depression.  I mean, after all, smart 
people don't suffer from mental illness. 
        I learned eventually that I did suffer from major chronic 
recurrent depression.  I finally sought treatment with the insistence 
and the help of a friend in November 2003.  I started receiving 
counseling and antidepressant medications, and at that time, it was 
covered by the law firm, and I had a great insurance program, but 
it was too little too late.  Not a month and a half after I started my 
treatment, I was called in by the partners and they said, we think 
you need to find opportunities outside the law firm.  Apparently, 
my lack of a team player attitude combined with my constant 
hangovers and runny noses were being noticed even though I 
thought I was doing a good job of hiding it.
        Once I left the big firm and went out on my own, somehow I 
was no longer able to get health insurance coverage because I had 
a mental illness, and I couldn't even get basic coverage in the State 
of Kansas where I lived because of that diagnosis.  
        But I was lucky, my parents had been able to foot the bill for 
me.  For the last few years, I have been out on my own, but I pay 
over $400 a month just for my mental health coverage.  Not 
everybody has the resources I have.  
        Today I am recovering from depression.  I have been in 
recovery about 2.5 years.  I just got married 3 weeks ago.  Life is 
going really great for me, but I do relapse.  When I do, I know I am 
not lazy or overly emotional or just feeling sorry for myself.  That 
is why I am so grateful and honored to be here today in the U.S. 
House of Representatives.
        Since I began speaking out about my depression just recently in 
an effort to reduce the stigma, I have been amazed by the millions 
of people who suffer from depression and the many people that I 
meet.  Just on the plane here this morning, someone saw me 
working on my testimony and preparing, and they leaned over and 
started to tell me their story of a friend who had suffered from 
bipolar disorder and committed suicide. 
        In February of this year, I made my first trip to Washington, 
D.C., with the Depression and Bipolar Support Alliance to 
introduce their groundbreaking research paper, The State of 
Depression in America.  I had the honor of sharing a podium with 
Mr. Mike Wallace and Representative Patrick Kennedy, and we, 
all three, got to talk about the effect that serious mental illness has 
had on our lives. 
        By removing the stigma of depression and helping people 
recognize that depression is a real illness, we bring the shadowed 
illness into the light of day and gave millions of people who are 
now quietly suffering from this excruciatingly painful illness the 
opportunity to seek treatment, treatment that we know can and 
really does help.  Thank you. 
        [The prepared statement of Jennifer L. Martin follows:] 


	I have always been aware of depression.  My mother has 
suffered from depression for as long as I can remember.  Her sister, 
my aunt, committed suicide in 1987 while suffering from 
diagnosed, but untreated, bipolar disorder.  I had even had small 
bouts of depression growing up, but never believed I could suffer 
from "mental illness."
	I am an attorney in Kansas City, Missouri.  I graduated at the 
top of my class from the University of Missouri - Kansas City 
School of Law.
	Not long after graduating and beginning my dream job with a 
prestigious Kansas City law firm, I realized something was wrong.  
I didn't smile or laugh.  Feelings of sadness and despair 
inexplicably began to cascade over me.  I had the perfect life (great 
job, good friends, money), but the world seemed dark and 
hopeless.  The fact that I should have been happy made my misery 
even worse.
	As an associate at a big law firm, I was expected to work long 
hours and weekends in order to meet the billable hour requirement, 
but I was frequently chastised by the partners in my firm because I 
was not hitting the bottom line and my attitude seemed poor.  I was 
told I didn't seem like "part of the team."  Instead of billing hours 
and being part of the team, though, I was living a secret life:  a life 
where I was abusing drugs and alcohol heavily and regularly in 
order to ease the pain of my depression.  Those drug and alcohol 
binges were always followed by even darker days where I could 
not even get out of bed.
	I was really sick.  But all I could think was that my employers 
would assume I was weak or lazy.  That I couldn't cut it in the 
corporate world and surely wasn't smart enough to work for their 
presitigous law firm.  After all, smart people don't suffer from 
mental illness.
	I have learned, though, that depression is a real disease brought 
on by a number of factors, including physical and chemical 
changes in the brain.  I have also learned that depression is a very 
treatable illness.  In November 2003, I began to receive counseling 
and anti-depressant medication, which was covered by the group 
health insurance plan at the firm.  By then, though, it was too late 
for my job.  My lack of billable hours, combined with my 
constantly runny nose and regular hangovers led the partners to 
suggest that I look for "other opportunities outside the firm."
	And, once I left the big firm and opened my own law practice, 
I could no longer get mental health insurance coverage. I am 
fortunate that I can afford to continue my treatment even without 
insurance coverage.  But what about the many people who cannot 
afford the $400 a month I pay?
	Today, I am recovering from depression.  I have a successful 
and growing law practice.  I just got married 3 weeks ago.  When I 
relapse, which I do, I know that I am not "lazy" or "overly 
emotional" or simply feeling sorry for myself.  I have depression - 
a real and serious illness that affects millions of Americans.  
	That is why I am so grateful and honored to be here today in 
the U.S. House of Representatives.  Since I began speaking out 
about my depression in an effort to reduce the stigma of depression 
for others, I have had been amazed by the millions of people I have 
met who are living with and suffering from depression and other 
mental disorders.  In February of this year, I attended and spoke at 
a press briefing for the Depression and Bipolar Support Alliance's 
presentation of the groundbreaking paper: The State of Depression 
in America.  I even shared a podium with Mike Wallace and 
Representative Patrick Kennedy.
	By removing the stigma of depression a and helping people 
recognize that depression is a real illness, we bring this shadowed 
illness into the light of day and give millions of people who are 
now quietly suffering from this excruciatingly painful illness the 
opportunity to seek treatment - treatment that we know can and 
does help.

        MR. DEAL.  Thank you.  
        Mr. Lamphere. 
 	MR. LAMPHERE.  Good morning, Mr. Chairman.
Congressman Stuckey from the great State of Georgia, who I 
had the privilege of working for some 30 years ago, always told 
me, if everything has been already said, when your time comes, 
you better tell some good stories. 
        And that I will try to do within 5 minutes. 
        A couple years ago, I was suffering in the third year of what 
would be characterized as the 99th percentile of severity of 
depression, a serious case. 
        I had taken some 27, 28 medicines, none had worked, that 27, 
28, did not include any cocktails or combinations of medicines 
which would have boosted that number considerably.  I have had 
41 electric shock treatments which were effective until the last 10 
or 12. 
        During all this, I had had a very supportive family and wife, 
but things proved a little too much, and I lost my wife to divorce, 
lost the family, lost the apartment, lost a good deal of my liquid 
assets, lost my job.  And finally, I was poured into a seat on the 
Acela and taken down to Baltimore to Johns Hopkins.  
Dr. DePaulo was there, and his predecessor, Paul McHugh, was 
there, and I said, gentlemen, you got to pull out all the stops; I 
don't care what the side effects are, pull them out. 
        And so they went back and got a class of drug that was over 
35 years old called Parnate.  It is an MAOI, rarely used, very hard 
to find in the drug stores, even in New York.  They combined it 
with a drug that was less than 2 years old called Geodon that had 
been invented not for depression but for hallucinations for 
schizophrenics and for bipolar with hallucinations but had been 
found by Johns Hopkins to be very, very effective in lower dosages 
with depression.  Thirty years old, and year and a half old. 
        The magic bullet was lithium and then Lamictal, which are 
mood stabilizers with antidepressant qualities. 
        They handed over that lobster roll, and they said, enjoy, 
because we think this is it.  One day later, I felt better.  I said let's 
put some more lobster in that one, and we added a little bit more.  I 
felt that much better.  I said, just keep going. 
        Sure enough, by the fourth or fifth day, I was back to my old 
self.  The story I want to leave you with is that I don't know if I 
could have made it if I didn't have the support of my family, at 
least until the end, or had the great wealth, and the perseverance, 
but the money to have taken advantage of the finest doctors in this 
country and finally find a teaching hospital that had the ingenuity 
to find the combination that would bring my particular 
predicament to a resolution. 
        My first point I want to make, Mr. Chairman, is, I honestly 
believe this is a physical illness.  It is not a mental illness.  The 
sooner we get that fact out in the educational system, in the 
elementary grades, the high school grades, the more people will 
        Let me tell you why I think it is a physical illness and what 
convinced me.  I was having a great debate with one of the great 
psychopharmacologists in New York, one of the finest, and I was 
telling him, psychologically, that these people who went to work in 
the morning looked like ants with briefcases on a treadmill.  I said, 
I don't know what they are laughing about.  I don't know why they 
take pleasure in sitting under a tree waiting in the shade.  He said, 
"Gil, this is not psychological.  This is all physical."  I said, "What 
do you mean?"  He said, "Well, you pay, I can't pay, and 
healthcare is not going to pay, but why don't you go down to NYU 
on 16th Street, and we will take some brain scans." 
        So I went down there, and they hooked up 25 electrodes to my 
head, and it looked like a Christmas tree.  It was bright red here.  It 
was beautiful blinking green here.  It was blue and white here.  We 
got here, and I said, well, that is the overview, but where is the 
detail?  Because they said, that is the detail.  It is black. 
        It is black.  It is not working. 
        It is gone.  I realized this is like charging a battery.  You have 
to have in the charging battery the right chemicals.  You have to 
have the right jumper cables.  You have to have the right ignition, 
and you have got to permeate that brain, which is in reference 
today.  I mean, the brain is designed to keep all this stuff out with 
good reason, but you've got to get it through there. 
        So it takes a long time to cure this illness oftentimes. 
        We talk about some of the illnesses, high blood pressure and 
diabetes and broken arms and Band-Aids.  That is exactly what this 
        It is a physical illness.  Our panel before us can talk about a lot 
of the environmental things that happen that we think are causative 
that people are prone to.  There is no question about that. 
        But what happens is, there is a snap.  The brain goes black.  I 
think that is what we have got to get across today is it is a physical 
illness.  I will stop there, Mr. Chairman. 
        [The prepared statement of Gilbert H. Lamphere follows:] 


	Good Morning.
	What is not on my resume is that I was severely depressed for 
3 years.  In fact, I was in the 99th percentile of severity.  Life was 
not worth living.  I had the finest psychiatric and 
psychopharmacological attention my fortunate wealth could 
access.  I had tried 27 medicines, not including combinations or 
"cocktails" of them.  I had 42 electric shock treatments to give me 
some respite.  I spent 75 weeks in and out of hospitals.  I had a 
loving wife that I lost to divorce 6 months prior to the end of my 
successful treatment.  I lost my family, I lost a good deal of my 
assets, I lost my apartment, my job and profession, and my father 
had a stroke.  
	Finally, when the last electric shock treatment had surprisingly 
failed, I was gifted by a friend who said "get down to Johns 
Hopkins".  There I was told I would be lucky, given the severity 
and duration of my illness, to regain 80% of normalcy, 80% of the 
time. Since normal for me is more like 120% and a blessed hypo-
manic state, not manic, just happy and positive and energetic most 
of the time,  I remember telling Dr. Raymond DePaulo and Dr. 
Paul McHugh, two of the outstanding psychiatrists in the world, 
that 80% wasn't good enough and to pull out the stops and we'd 
worry about side effects later.  And so we did, because that's their 
philosophy anyway-pull out the stops, think outside of the box, in 
fact, collapse the box entirely.  
	So here I am today.  Hopkins gave me a 30 year old, off 
patented, class of depressant called Parnate (an MAOI), invented 
in the early 70's, together with a 2 year old drug designed for 
calming hallucinations in bipolar and schizophrenics, but which 
Hopkins had discovered had powerful anti-depressant behavioral 
effects at low dosages.  Add to this mix, Lithium and Lamictal as 
mood stabilizers with anti-depressant qualities and we had the 
perfect cocktail.
	I spent 12 weeks off and on at the hospital.  My wife and 
children never visited me for reason I still don't fully understand.  
But it's very possible they had been advised not to get further 
swept up in the vortex of an illness that eats marriages alive, until 
we got the fine tuning right.  And here we are two and a half years 
later, and I feel better today than I ever remember in my life.
	Against this backdrop, I have just 2 points to make today.
	First, depression, bipolar and its related cousins are not mental 
illnesses.  They are physical illnesses, in both cause and treatment.  
Allow me to explain.  In the middle of my illness, Dr. Francis 
Maas, one of New York's premier psycho-pharmacologists, told 
me that part of my brain affecting emotion and cognitive behavior 
was shut down, non functioning.  I didn't believe him, since I 
thought I was right in all my thinking, e.g., that nothing was 
humorous, nothing gave pleasure, people going to work in the 
morning was a repetitive tragedy like ants with no brains, etc.  To 
prove my point that my psychological insights were correct, I went 
down to New York University Hospital were they hooked up my 
head to 25 electrodes and for a half hour recoded my brain 
functions.  Then I looked at the printouts.  It looked prettier than a 
Christmas tree.  My brain's right front was blinking red, my back 
right was blinking green, my left back was blinking yellow and 
blue and my front left was-holy smokes-it was black with 
nothing going on.  
	Mental illness may have gotten its name by being lodged in the 
brain, but at its core, it is not psychological (although counseling 
can help after the brain is lit up enough) illness.  It is a physical 
illness like diabetes, high blood pressure or a broken arm, which 
things like extreme stress triggers.  There can be a predisposition, 
or there can be not trigger at all.  But suddenly, the physical 
components of the brain, the electrons, the chemicals, the neurons, 
the  reuptakers, electrical charges don't work.  And my point is, if 
these disorders are thought of correctly, as physically caused and 
physically cured, mental illness will be called a brain problem, 
seen entirely differently and the stigma will melt away.  
Incidentally, I find this insight to be most easily accepted by 
people under the age of 60 and not so easily accepted by people 
over 60 (mostly men) who feel if you are depressed you should 
"pull yourself up by the bootstraps and regain the respect of your 
wife, family and friends."
	My second and last point today, is that finding the right 
medicine or combination of medicines can often be a long drawn 
out process.  We seem to understand what we are trying to 
stimulate in the brain, and medicines today are targeted, with 
variations, to do that.  But it is still hit and miss.  We need to 
manage patients expectations while, at the same time, give them 
hope.  But medicines sometime take a long time to fully work, and 
sometime the patients grow discouraged that he/she is not getting 
better and the doctor has moved the goal post another 100 yards 
down the field.
	In summary, we have a physical  ailment, not psychological, 
that is treated physically, and that is difficult to treat and takes 
time.  Thank God I have had my family for much of the time, and 
my wealth to get me through. How other people without those two 
ingredients struggle through the months and years of being without 
human support, a job, money and the finest care in the United 
States, is beyond me.

        MR. DEAL.  Thank you.  
        Mr. Earley. 
 	MR. EARLEY.  Thank you.  
        My name is Pete Earley.  I am the author of, "Crazy: A 
Father's Search Through America's Mental Health Madness."  I 
am also the proud father of a 27-year old son, Mike, who happens 
to have a brain disorder. 
        His illness surfaced while he was in college in New York.  His 
brother called me one day in a panic and said, Mike has gone 
crazy.  I drove immediately to New York to get him from my home 
in Virginia.  It is difficult for me to tell you how painful it was to 
ride home with him on that day. 
        During the 4-hour drive, his moods would shift within seconds, 
crying at one moment, laughing at the next. 
        He said to me, "Father, how would you feel if someone you 
loved killed himself?"  I did what any parent would do.  I drove 
him to an emergency room. 
        I will never forget the intake nurse rolling her eyes as Mike 
described how he was getting secret messages from God.  We 
waited for 4 hours.  A doctor came in.  He came in with his hands 
up as if he were surrendering, and he said, "I can't help your son."  
I said, "You haven't even looked at him."  He said, "It doesn't 
matter.  Your son has told the nurse that he believes pills are 
poison, and under Virginia law, I cannot treat anyone against their 
will unless they are in an imminent danger to themselves or 
someone else.  Take him home and bring him back when he tries to 
kill himself or kill you." 
        The next 48 hours, I watched my son sink into a mental abyss.  
At one point, he had tinfoil wrapped around his head because he 
was convinced the CIA was reading his thoughts.  He slipped out 
of my house.  He broke into a stranger's house to take a bubble 
bath.  Five officers had to go in and wrestle him out. 
        They took him to a community treatment program.  I arrived, 
and the policeman outside said, unless you go in there and you tell 
his psychiatrist that your son tried to kill you or kill himself, he 
will not be admitted.  I said, he hasn't done that.  He said, it 
doesn't matter, under the law, he has to be in imminent danger to 
himself or others.  So I went in, and I lied.  My son was put in the 
hospital.  A few days later the police called me.  My son had been 
charged with two felonies, breaking and entering, and destruction 
of property. 
        I was so frustrated.  Our laws had stopped me from getting him 
help.  Now the laws wanted to punish him for a brain disorder. 
As a father, there was little I could do.  As a journalist, I could 
investigate our system. 
        I quickly discovered that my Mike was not alone, because of 
deinstitutionalization and our flawed system, there are 300,000 
persons with severe mental disorders in our jails and prisons; 
500,000 on probation; 700,000 go through our justice system every 
year.  The largest public mental facility in the United States is not a 
hospital; it is the Los Angeles County jail. 
        Mike ended up being sentenced to 2 years of probation.  He 
completed treatment.  He took his medication.  Everyone told him 
mental illnesses are chemical imbalances.  They are biologically 
based.  The heart gets sick.  The mind gets sick.  There was 
nothing for him to feel ashamed about, but when Mike told 
potential employers he had a mental illness, his application was 
rejected.  My son has a college degree.  He was refused a job 
bagging groceries.  
        Six months after Mike's probation ended, he stopped taking his 
medication.  Because of my research, you would think I would be 
smart enough to protect him.  But I found myself again being 
stymied.  When I called the Fairfax County Mobile Crisis Unit for 
help, the dispatcher asked if Mike were dangerous.  Not yet, I said.  
Then there is little we can do to help him.
        I begged.  I pleaded.  I badgered my son to take his medicine.  
But he refused, and he got worse.
        A month ago, 4 weeks ago, his mother and I called the Fairfax 
County Mobile Crisis Team.  Mike had become violent.  The 
dispatcher told us, call the police.  We don't answer calls if the 
person is violent.  I was afraid of the police.  I was afraid they 
would arrest him.  I was afraid they would harm Mike or he would 
harm them.  So I called a social worker who is a close friend who 
works with the police department.  He got out of his bed at 
midnight and came over.  He insisted that the police call a sergeant 
who is equipped with an electric stun gun, a taser.  He was sent to 
our house.  Mike ended up being shot twice with the taser.  He was 
hog-tied, and once again, he was taken to a community center 
instead of to the jail. 
        It took us 3 hours before we could see a doctor on duty.  
Luckily, he agreed to hospitalize Mike.  It took 3 more hours to 
find a hospital with a vacant psychiatric bed, and they only agreed 
to take my son after they learned he had insurance. 
I live in one of the wealthiest counties in America.  It can take 
a person with a severe mental illness 6 months to get into a 
treatment program, 2.7 years to get a case manager, 17.5 years to 
get into subsidized housing.  You have asked me what it is like to 
be a parent with a person with a mental disorder.  Each time my 
son laughs, I wonder if he is taking his medication.  Each time he 
becomes sad, I wonder if he is heading for another relapse.  Each 
time the phone rings, I shudder.  I live on an emotional cliff 
waiting for the next breakdown.  But I also cling to the hope that 
Mike will find a way to control his illness, that science and therapy 
will curb his disorder.
        I try to focus on persons such as my panel members for 
inspiration.  I look to you for leadership, leadership that will bring 
an end to the criminalization of persons with mental illnesses, 
leadership that will bring about sensible reforms, leadership that 
will enable Mike and other sons and daughters to get help and not 
be turned away by a doctor when he says, bring him back when he 
tries to kill himself or kill you.  Thank you. 
        [The prepared statement of Pete Earley follows:] 


        Summary: When journalist Pete Earley's adult son, Mike, 
developed a major mental illness, his father rushed him to an 
emergency room, but a doctor there refused to treat him, citing 
civil rights laws that said Mike had to be an "imminent danger" 
either to himself or others before he could be helped against his 
will. Mike thought pills were poison. Earley was told to bring his 
son back if he tried to kill himself or someone else. Forty-eight 
hours later, Mike broke into an unoccupied house to take a bubble 
bath during a psychotic episode. He was arrested and charged 
with two felonies: breaking and entering, and destruction of 
property. Earley was so outraged by a legal system that had 
stopped his son from getting help and now wanted to punish him, 
that he launched his own investigation into today's mental health 
system. He eventually spent a year inside the Miami Dade County 
jail in Florida where he followed several mentally ill prisoners 
through the court system and into the community. He interviewed 
correctional officers, judges, attorneys, mental health workers, 
psychiatrists, the police, parents of persons with mental illnesses, 
and consumers to learn why jails and prisons have become our 
new mental asylums. He has published his findings in a nonfiction 
book, CRAZY: A Father's Search Through America's Mental 
Health Madness, which tells two stories. The first is his son's. The 
second is an expose that explains how persons with mental 
illnesses are being treated today. Earley concludes that we need to 
take immediate steps to stop the criminalization of persons with 
mental illnesses by: re-examining our nation's commitment laws, 
establishing Crisis Intervention Training for the police, stopping 
the closing of psychiatric hospital beds, and by improving 
community based treatment services.

        Thank you for inviting me to testify this morning about my 
son, Mike, and what it feels like to be a parent or a loved one of a 
person with a serious mental disorder.  The quick answer is: 
frustrating and heartbreaking. It is difficult enough to battle a 
biological brain disorder. It is even more frustrating and more 
heartbreaking when you encounter a mental health care system that 
is callous and so deeply flawed that it throws up roadblocks to 
recovery rather than offering a helping hand.
        I have included an excerpt of my book, CRAZY: A Father's 
Search Through America's Mental Health Madness, in this written 
testimony. It will explain how we are turning persons with mental 
disorders into criminals, how jails and prisons have become our 
new mental asylums, and how we have gotten ourselves into this 
tragic yet preventible mess.
        Please read it.  I live in one of the most affluent and 
sophisticated suburbs in America in a Virginia county that prides 
itself on having a model mental health care system, yet my son 
ended-up being punished - rather than treated -- because of his 
illness. Sadly, what happened to him is not an aberration.
        There are 300,000 persons with severe mental illnesses 
currently in our jails and prisons. Another 500,000 are on 
probation. 700,000 go through the court system each year. Those 
who aren't in jail, oftentimes are hidden away in repugnant 
assisted living facilities. In Miami, 4500 persons with severe 
illnesses are housed in 647 rooming houses. 397 of these slum 
operations can't pass the state's minimum standards for boarding 
homes, yet Florida continues to use them. We have closed down 
the giant warehouses that were state mental asylums. But sadly, we 
have not helped thousands of persons with severe disorders. 
Instead, we have simply hidden them better. 
        As we have heard today, we have made significant advances in 
developing medications and treatment. But none of these 
promising scientific discoveries will matter if we cannot find a 
reasonable and sensible way to deliver services to persons who 
need help.  As you read my son's story, you will discover that 
getting help is often nearly impossible even when medical 
solutions are available.  Please remember two additional facts. 
Mental disorders can strike anyone regardless of their race, creed, 
political clout, or wealth. Bipolar disorder, severe depression and 
schizophrenia are equal opportunity afflictions. If it happened to 
my son and me, it can happen to your son, daughter, mother, 
father, or sibling. Also understand that I am not alone in asking for 
reform. Consider this note that was written by a mother who posted 
it on my author's webpage (www.peteearley.com). 
        "Only a parent with a seriously mentally ill child, like yourself, 
can understand the terror and desperation that  we suffer. I live 
constantly with the threat of my adult son's arrest or death (or 
worse) and I have even harbored the horrible thought of taking 
my own life and his on occasion to just end this never-ending 

        This mother is suffering, not only because of her son's mental 
illness, but by her inability to get him meaningful help. Science 
can give us the tools to unlock the brain's mysteries. But these 
discoveries are useless if we can't develop a mental health care 
system that can provide services and treatment. My son's story is a 
testament that such a system does not exist today. What I found 
during my year long investigation at the Miami Dade County jail is 
a testament that such a system does not exist today. We need 
Congress to fix these problems.
        I applaud your committee for taking an important step today by 
holding this hearing and calling attention to the need to end stigma. 
But please don't stop here. I beg you. My son, Mike, has a mental 
disorder that is trying to destroy him. He and I have no choice but 
to put our trust in medical research. But whether or not Mike ends 
up living on the street, eating out of a garbage can and being 
attacked by teenage thugs wielding baseball bats -  or living in a 
rat infested assisted living facility -- or spending the rest of his life 
locked in a jail cell for a crime that could have been prevented - 
these are scenarios that are within our control.
        Here is our story. I wrote it because I wanted mental illness to 
take on a human face. It is my son's, but it is a face that can be 
worn by thousands. 
                *****     *****     *****
        "How would you feel, Dad," Mike asked me, "if someone you 
loved killed himself?"
        My son's voice sounded weary. We were speeding south on 
Interstate 95, just north of Baltimore, racing toward a Fairfax 
County hospital. I had rushed to Manhattan earlier that morning to 
get Mike after his older brother telephoned me in a panic. They 
both lived in New York City. Mike had not slept in five days, had 
been walking aimlessly throughout the city, and was about to lose 
his job as a waiter. He was convinced God was sending him 
encrypted messages.
        Without warning, Mike burst into laughter. "Dog God!" Ha, 
ha, ha.  "God Dog! Get it?"
        Just as quickly, he began to sob. Tears flowed down his cheeks. 
I hadn't seen him in such pain since he was a boy and got smacked 
in the scalp with a stick by a playmate. I had driven him to the 
hospital and held his hand while they sewed stitches. He had been 
five years old back then. Now he was twenty-three.
        "Why are you crying?"
        "I can't tell you because you will hate me forever."
 	My wife, Patti, already had alerted the emergency room at 
Inova Fairfax Hospital. It's where we had taken him before when 
he'd suffered a mental breakdown a year earlier. There had been 
no warning signs, no known family history of mental illness. Mike 
had recently graduated from a Brooklyn art school when one of his 
friend's had showed up with him at my front door. He was 
babbling about a girl named Jen, telling me that she was in danger, 
that people were going to hurt her and that he needed to save her. 
None of it made sense. I put him to bed, but he became paranoid 
and when I finally was able to persuade him to go to the hospital, 
security guards had to wrestle him down. That was when I had first 
heard the term: bipolar disorder. 
        With anti-psychotic medication, time, and therapy, Mike had 
become his old self again and returned to New York. I called every 
Sunday but our recent conversations had been shorter than ususal. 
Still, I'd not suspected that anything was wrong. The truth was that 
both of us wanted desperately to believe the doctors had made a 
mistake, that he had been misdiagnosed and his first episode had 
been a fluke brought on by too much stress and too little sleep.
        But then his brother called. Mike had not been taking his pills 
and now he was acting crazy.
        "Please take your medicine," I begged. I'd been trying to get 
Mike to take Zyprexa, an anti-psychotic, since he'd first gotten into 
my car.
        "Pills are poison."
        But moments later, he said:  "Okay, I'll take your damn pill." 
He reached for the water bottle that I'd given him, but he paused 
before he slipped the tablet into his mouth and then dropped his 
hand next to the car seat out of my view. Was that the pill? 
        I pressed harder on the gas pedal. I had to get him to the 
hospital. He would be safe there. Its doctors would know what to 
                        *****   *****    *****
        I had no idea.
     	I had been a journalist for more than thirty years, a Washington 
Post reporter, and the author of several nonfiction books about 
crime and punishment and society, some award-winning, even 
best-selling. I'd interviewed murderers and spies, judges and 
prosecutors, defense attorneys and defendants. But I was always on 
the outside looking in. I had no idea what it was like to be on the 
inside looking out - until Mike was declared mentally ill. 
     	Our manic trip from New York City to Fairfax in late August 
2002 was the start  of a harrowing journey. We were about to 
plunge headlong into the maze of contradictions, disparities, and 
catch-22s that is America's mental health system. But even that 
was nothing compared with what happened when Mike, suffering 
delusions, committed a crime and was arrested, thrusting us into a 
judiciary that proved ill-equipped to handle madness.
    	Few of us worry that we'll wake up mentally ill. But what if 
the phone rings, and it's someone telling you about your sister, 
your daughter, your mother or your son? It happens more than you 
think. Fifty-one million Americans have mental disorders. Nearly 
all Americans have at least one relative who is mentally ill. Six-
and-a-half million Americans are so debilitated by mental illness 
they are considered disabled. 
Because of what happened to Mike, I have spent the last four 
years examining our nation's mental health system from an 
unusual perspective -- as a father struggling to help his son and as 
a journalist investigating a larger story. What I have discovered 
should outrage us. It should also scare you. Because the way we 
treat the mentally ill today in America is a national disgrace and 
mental illness is indiscriminate. Your education, your income, your 
political clout, your zip code - none of it matters. 
       	If it could happen to my family, it could happen to yours.
                        *****     *****     *****
      	By the time we reached the hospital it was eight p.m.  The 
intake nurse rolled her eyes as Mike blabbed about God. She put us 
in an examination room to wait. For the next two hours, no one 
came to help us. Another hour passed and then, incredibly, another. 
It was now midnight.
        "I'm leaving," Mike declared.
        I stepped out and flagged a nurse. An emergency room doctor 
came in moments later. As he stepped toward Mike, the doctor 
raised his arms as if surrendering to enemy troops. "There's not 
going to be much I can do for you," he announced.
       	I thought: You haven't even examined him!
      	The doctor asked Mike: "Do you know who I am?"
       	"You're the witch doctor. Owe-ee-ow-ah-ah."
       	The doctor grinned. This isn't funny, I thought. I blurted 
out: "He's been hospitalized before for bipolar disorder. He hasn't 
been taking his medication."
 	But the doctor cut me short. "What's happened before this 
moment really doesn't matter." He asked Mike to name the 
president. Then had him count backwards from a hundred. "What 
does the phrase 'Don't cry over spilled milk' mean?" Mike 
answered each question and then added that God had made him 
       	"Virginia law is very specific," the doctor explained. 
"Unless a patient is in 'imminent danger to himself or to others,' I 
cannot treat him unless he voluntarily agrees to be treated." Before 
I could reply, he asked Mike, "Will you take medication?"
       	"I don't believe in your poisons. Can I leave now?"
       	"Yes," the doctor said. Mike leaped from the exam table 
and hurried toward the exit. 
        "But he's not thinking clearly," I stammered.
        The doctor shrugged. If Mike tired to kill himself or hurt 
someone, he said, I could bring him back.
                        *****     *****     *****
 	During the next twelve hours, I listened to Mike as he slipped 
deeper and deeper  into a mental abyss. Nothing can prepare a 
parent for this horror - watching your child being tormented by his 
own thoughts. In the morning, I decided to spike his breakfast 
cereal with an antipsychotic medication. But Mike spied flecks of 
the pill's pink shell floating in the milk and erupted. "Take me to 
mom's house!" he yelled.
      	His mom is my ex-wife, who lives nearby. During the 
drive, he became so furious at my badgering about his pills that he 
jumped out before I could bring the car to a full stop. He ran the 
rest of the way there.
     	Forty-eight hours later, the Fairfax County Police called. Mike 
had been arrested. He'd gotten up before sunrise and gone outside. 
Suddenly, he'd felt filthy, so dirty that he had to take a bath - 
immediately. He shattered a glass patio door at a stranger's house 
and darted in. Fortunately, the homeowners were away for the 
weekend. After rummaging through the kitchen, Mike went 
upstairs to take a bubble bath. Alerted by the home's clanging 
burglar alarm, the Fairfax County Police sent a dog inside. It bit 
into Mike's arm and dragged him down. But it still took six 
officers to subdue him. 
     	The police drove Mike to the Woodburn Center for 
Community Mental Health, less than one mile from the Inova 
emergency room where I'd first taken Mike for help and been 
turned away. None of this would have happened if that damn 
doctor had treated Mike, I thought as I turned into the Woodburn 
parking lot.
                        *****     *****     *****
       	Police Officer Vern Albert was standing at the entrance. 
"Even though your son has broken into a house, unless you tell the 
medical personnel inside that he's threatened to kill you, they 
aren't going to treat him. We'll end up taking him to jail and you 
don't want that. Not in his mental condition."
 	"But he hasn't threatened to kill me."
       	Albert shot me an exasperated look.
       	I went inside, and I lied. The police drove Mike to the 
psychiatric ward at Inova Mount Vernon Hospital in Alexandria. I 
followed. "How long does it take anti-psychotic medicines to 
work?" I asked a nurse there.
       	She seemed surprised. "Just because your son is being 
admitted doesn't mean he's going to be treated," she said. It was 
against the law for doctors to force Mike to take anti-psychotic 
medication, she explained, even though he was clearly psychotic. 
       	An attorney called a few hours later and explained she had 
been appointed to represent Mike. I was excited because I naively 
thought she was going to help me get Mike treatment. But she 
explained it was her job to get him released as quickly as possible 
if that is what he wanted.
       	"But he's not thinking clearly!" I snapped. "He's sick."
       	"I'm just doing my job," she replied.
                        *****     *****     *****
      	At a commitment hearing the next morning in the hospital, 
Mike agreed to sign himself into treatment voluntarily. 
       	"Why are you doing this?" the hearing officer asked.
      	"Because I'm having a relapse and my parents want me 
somewhere safe."
 	I felt relieved. Now he could finally get help. That night, I 
brought Mike a box of fast food chicken. I knew he wouldn't like 
hospital food. It happened to be my fifty-first birthday and despite 
his confused mental state, Mike remembered and  handed me a 
hand-drawn card. From nowhere, he mentioned a fishing trip to 
South Dakota we'd taken. He'd been five and had wandered off 
from the lake. The ground had given way at the edge of a ravine, 
causing him to fall half-way down it before he'd grabbed a shrub 
and stopped the fall. I'd climbed down and rescued him. Over 
time, the story had grown. The gully had become a hundred-foot-
cliff. That was when he was little, and I was still his hero. We 
laughed about the story and then I said:  "Get well, son, that will be 
the best birthday gift ever."
      	The next morning, the hospital psychiatrist called. A pill 
had been found on the floor in Mike's room. He'd pretended to 
take it and then spit it out. I confronted him that night.  "I keep 
thinking this is all a dream," he said. "I'll just wake up and it didn't 
       	I touched his hand. "This is real. You've got to take your 
       	Dr. James F. Dee called the next morning. Mike was taking 
his pills, but there was a new problem. Our insurance company 
wanted Dr. Dee to discharge Mike later that day. Dr. Dee didn't 
believe Mike was ready, but because Mike hadn't tried to kill 
himself and was now taking his pills, the insurance company 
wanted him out.
       	I called the insurance company, but the woman there had 
no sympathy. "Your son can recover at home."
 	"But he's not stable!" I said, and then I lost it and I did 
something that I had never done before as a journalist. I warned 
her that I was a former Post reporter and was friends with Mike 
Wallace of 60 Minutes. If her company forced Mike out, I'd notify 
the Post. I'd call Wallace. As I put down the receiver, I realized 
that since Mike's breakdown, I had lied to get him hospitalized and 
now I was violating my professional ethics to keep him there. 
      	Dr. Dee telephoned that afternoon and said the insurance 
company had backed off. Mike could stay in the hospital as long as 
necessary. I learned later that a girl, who had stabbed herself in the 
neck with a pencil, had been released that day. Within two hours, 
she had disappeared, leaving her parents to drive the streets. 
      Mike slowly got better and we arranged for him to enter a 
community mental health day treatment program in Reston. I 
began to feel optimistic. And then the phone rang. 
       	"I'm Detective V.O. Armel," the caller said. "Two felony 
warrants have been issued for your son's arrest." Mike had been 
charged with "intentionally destroying, defacing, and damaging 
property in excess of $100" and "breaking and entering...with the 
intent to commit larceny." Both carried up to $10,000 in fines and 
five year prison terms.
       	"But my son's mentally ill," I protested. "He didn't know 
what he was doing. And I tried to get him help in a hospital before 
this happened."
 	"Just because your son is mentally ill doesn't mean he can't be 
charged with breaking the law."
                        *****     *****     *****
        What happened to Mike was not uncommon. A major shift 
has occurred in America.
        In 1955, some 560,000 Americans were patients in state 
mental hospitals. Between 1955 and 2000, our nation's population 
increased from 166 million to 276 million. If you took the patient-
per-capita ratio that existed in 1955 and extrapolated it out based 
on the new population, you'd expect to find 930,000 patients in 
mental hospitals today. But there are fewer than 55,000.  Where 
are the others?  More than 300,000 are in jails and prisons. Another 
half million are on court-ordered probation. The largest public 
facilities for the mentally ill are not hospitals. They are jails and 
prisons. They have become our new asylums.
        Why? I decided to go to Miami, Florida to find out. I chose it 
for two reasons. I didn't want to risk irritating local officials in 
Fairfax by writing about the jail system here since they would be in 
charge of deciding Mike's fate. I also had been told that Miami has 
a higher percentage of mentally ill residents than any other major 
city. Three percent of the population in most American cities are 
mentally ill. In Miami, it's nine percent. Besides the normal three 
percent, another three percent come for the warm weather and 
another three because of Fidel Castro. In 1980, he released patients 
in Cuba's mental hospitals into the stream of refugees fleeing to 
Florida from the port of Mariel. 
      	Miami has been struggling with mixed success to deal with 
its mentally ill. It proved representative. I could just as easily have 
chosen Chicago, Los Angeles, Philadelphia or Washington D.C. 
Miami's jail system is the fourth largest in the nation. Sixteen 
percent of its inmates have severe mental disorders. The craziest 
are housed on the ninth floor in the downtown jail in "suicide 
watch" cells with plexiglass front walls so officers can keep an eye 
on them.
    	Dr. Joseph Poitier, the jail's psychiatrist, took me on his 
morning rounds. As we entered C wing, I gagged.  The air stunk. It 
was a putrefied scent, a blending of urine, expectorant, 
perspiration, excrement, blood, flatulence, and dried and discarded 
jailhouse food. I listened to the sounds. Toilets flushed. Prisoners 
hacked, coughed, groaned. Correctional officers laughed and 
yelled commands. Leg chains click-clacked against the hard 
surface as prisoners arrived. These were typical jail noises. When I 
listened closer, I heard the asylum sounds. A prisoner sobbing 
uncontrollably, another moaning, a third screaming.
      	Thud, thud, thud.. Then faster. Thudthudthud. Then louder. 
THUD. THUD. THUD. An inmate was banging his forehead 
against a glass cell front.
 	The inmates peering out at me in the first cells were naked. 
There was nothing in their cells except a combination sink and 
toilet. Nothing. No television, no radio, no magazine, no place to 
sleep, no chair. Nothing. Because of a design flaw, the temperature 
in each cell hovered in the 60s. The inmates were trembling in the 
frigid air. A few rocked back in forth on their heels, mumbling. 
Some had urinated and defecated on the floor.  Most stood at their 
cell fronts looking out at the officers. They had blank expressions, 
hollow eyes. I had never seen such bleak conditions and I have 
been in hundreds of jails and prisons as a reporter. 
     	"What I do here is triage," Dr. Poitier explained. There is no 
meaningful treatment. As we shifted from cell to cell, he spent his 
rounds trying to persuade prisoners to take medication. They had 
arrived on C wing with no medical records. Many were homeless.  
Most of their families have given up on them. Psychotic inmates 
could spend months here. Others would be released only to be 
arrested within hours on different charges related to their illnesses, 
such as trespassing or being a public nuisance. If they were 
charged with a felony, they would eventually be sent to one of 
Florida's three forensic hospitals. But there was a long waiting list 
and even then, they were not treated there. Instead, they would be 
given medicine until they were judged "competent" for trial and 
returned to Miami. Sometimes it could take five or six trips 
between the jail and hospital before they were stable enough to 
appear in court.
        We paused outside a cell designed for two men, but holding 
six. A prisoner was lying on the floor next to a toilet that another 
was urinating in. Because the splash was hitting the inmate's face, 
Dr. Poitier was concerned. He asked a prisoner to roust the man to 
make certain he was sleeping and not dead. The inmate raised his 
head, grunted, and rolled over. As we were about to move on, I 
notice movement underneath a steel bunk. Dropping to my knee, I 
peered through the smudged glass wall. A man was curled up 
there. He had schizophrenia, which can cause hallucinations and 
confused thinking, and was chewing on day-old orange peels. He 
smiled and waved.
      	I checked my watch after we finished the morning rounds. 
Dr. Poitier had spoken with or visibly observed ninety-two 
inmates. His rounds had taken 19 � minutes. That was an average 
of 12.7 seconds per prisoner.
      	"A lot of people think someone who is mentally ill is going 
to get help if they are put in jail," Dr. Poitier said. "But the truth is 
we don't help many people here... we can't."
      	A man with bipolar disorder, which causes rapid mood 
swings, had been put in jail. For twenty-five years, he'd taken his 
medication and lived an ordinary life.  But then he'd lost his job 
and couldn't afford his pills. He'd attacked his father and been 
arrested. In jail, he jumped from a top bunk headfirst into the floor, 
snapping his neck. Now, he was a paraplegic.  
     	"Jails are not hospitals," Dr. Poitier said. "Mentally ill people 
belong in hospitals, not here."
     	That night I woke up sweating. I had dreamed I was with Dr. 
Poitier making rounds and had spied an inmate under a bunk. 
When I bent down to see, the inmate eating the old orange peel 
was Mike.
                        *****     *****     *****
        In a well-schooled Virginia drawl, Fairfax defense attorney 
Andrew Kersey assured us that he'd be able to cut a plea bargain 
for Mike. Because my son had no previous criminal record, was 
clearly psychotic when he broke into the house, and was now in a 
treatment program, Kersey felt confident the Fairfax County 
prosecutor assigned the case would reduce the two felony charges 
to misdemeanors. Mike would be given a year of probation. It 
would be an open-and-shut matter.
      	On the morning of his court appearance, I asked Mike if he 
understood what was happening. He didn't. He was still groggy 
from medication, but he was eager to go to court. When I asked 
why, he replied: "I get to wear my new suit!"  Before he'd become 
manic, he'd bought a suit because he was going to interview for a 
new job. This would be the first time he had worn it.
     	"There's a problem," Kersey announced moments before the 
hearing.  "Our plea deal is off." He explained that the assistant 
prosecutor had never cleared the deal with the homeowners and 
when they heard about it this morning, the wife had gotten angry. 
    	"She wants your son put in jail or an institution," Kersey 
explained. "The victims are demanding he plead guilty to at least 
one felony charge."
     	"But a felony will ruin Mike's future." His college degree was 
in a profession that required a Virginia state license. Felons were 
Kersey gave us a sympathetic look and said: "What's odd is the 
judge will still give Mike the exact same sentence." If Mike 
pleaded guilty to two misdemeanors, he'd get a year of probation. 
If he were forced to plead guilty to a felony, he would still get a 
year of probation.
      	Kersey wasn't certain if the wife understood this, so he 
ducked back into the courtroom to talk to her, leaving us to wait in 
the hallway. I checked my watch. Six minutes to go before court 
started. A few moments later, Kersey reappeared. The husband 
didn't care but the wife wanted Mike punished. Before Mike took 
his bubble bath, he broke a family heirloom dish, turned photos of 
her children face down on the mantel, drank some booze and left 
the bathwater running in the house causing extensive damage. 
Most of all, Kersey said, the wife felt violated. Mike had taken a 
bath in her teenager daughter's bathroom. That's creepy. Why had 
he chose their house? What if he came back? She was so unnerved 
that she was pressuring her husband to sell their house and move 
    	"What she really wants is for your son to be put in prison," 
Kersey said.
     	"But he's mentally ill. Bipolar disorder is a chemical brain 
disorder. It's like cancer. You get it. You don't do anything to get 
it. It just happens to you," I said.
Kersey nodded at his watch. Four minutes. He explained our 
options. If Mike pleaded guilty to a felony, the case would be over. 
If he pleaded not guilty, the judge would set a trial date. But a jury 
would probably find Mike guilty because he'd been arrested inside 
the house. It might send him to prison. There was a third choice. 
Mike could plead "not guilty by reason of insanity" but if we won, 
he would not be turned loose. He would be taken directly from the 
courtroom to the jail to wait for a bed in a Virginia forensic 
hospital. Mike could spend weeks waiting and there would be no 
way to know when he might be released after he was sent to the 
hospital. He'd also be identified in court records forever as being 
innocent, but insane. 
      	"We'd win in court," Kersey said, "but your son would 
       	Three minutes and ticking. Three minutes to decide which 
was the lesser of three punishments that, as Mike's father, I 
believed were all unfair. 
     	"Offer them money," I said. Kersey said no. The wife was 
legitimately afraid. She felt twice victimized. Mike had broken into 
her house. The prosecutor had not consulted her about the plea 
deal. She was the victim, not Mike, and in today's  get-tough-on-
crime environment, no elected prosecutor wanted to appear soft on 
      	Two minutes.
      	"What do you want to do?" Kersey asked.
      	I didn't know. How could this be happening? Kersey 
suddenly had another idea. He'd ask Detective Armel for help. The 
police often bond with victims. He rushed back into the courtroom.
Mike and I waited. He didn't have any idea what was 
happening. When Kersey rejoined us, he shook his head. Nothing 
had changed. Detective Armel had explained that Mike's 
punishment would be the same, but it hadn't mattered to the wife. 
     	We were out of time. Mike and I followed Kersey into the 
courtroom. I noticed Detective Armel was still speaking to the 
victims. I didn't know what to tell Kersey. Which was better? 
Pleading guilty to a felony and having Mike marked for life? 
Risking a trial and having him found guilty? Or fighting the 
charges by pleading that Mike was insane? I'd been given less than 
ten minutes to make a decision that was going to forever alter my 
son's future. 
     	The judge entered. The clerk began reading the calendar of 
cases. Mike's name was third on the list. For the first time in my 
life, I was literally frozen with indecision. I looked at Mike. I 
looked at Kersey. He needed an answer. 
      	At that moment, I saw Detective Armel walk down the 
aisle to talk to the prosecutor. I glanced at the husband and wife. 
She was sobbing. But I felt no sympathy.
    	Kersey hurried up to Armel. The clerk called Mike's name. 
The prosecutor said, "Judge, we'd like to continue this case." 
     	The judge agreed to put it aside for three months.
     	Kersey hustled us out into the hall. Detective Armel had won 
us more time by telling the wife that Kersey might be able to come 
up with an offer that would be better for them than one year of 
     	The homeowners and Armel exited the courtroom. None 
looked at us.
      	"Mike," I said, "do you see those people walking there?"
He looked and had no idea who they were.
                        *****     *****     *****
     	Dorothea L. Dix visited a Boston jail to teach a Bible class in 
the 1800s and discovered mentally ill prisoners had no heat despite 
freezing temperatures. The jailer said: "The insane don't need 
heat."  Dix spent the next two decades exposing how "lunatics" 
were being abused in jails and prisons. She would be credited with 
persuading thirty states to build asylums for treating the mentally 
ill, rather than punishing them because they were sick.
        By 1900, every state had a mental institution, but conditions in  
them were wretched. Patients were often committed by relatives. 
The system was abused and the hospitals became a catch-all for 
society's disposables  - the elderly, the deaf, the blind, and the 
poor.  On May 6, 1946,  Life magazine published a story entitled: 
Bedlam: Most U.S. Mental Hospitals Are a Shame and a Disgrace. 
It began by describing a mental patient being tortured to death by 
the staff.  Other investigative stories compared conditions in state 
mental hospitals to Nazi concentration camps.
     	In 1963, President John F. Kennedy asked Congress to spend 
three billion dollars to replace the nation's cruel state hospital 
system with a network of Community Mental Health Centers. The 
discovery of promising new antipsychotic drugs made it possible 
for severely mentally ill patients to return to their hometowns and 
live outside locked wards. 
        It was a grand plan, but Kennedy was assassinated, the 
Vietnam war escalated, Congress got ensnared in Watergate, and 
the mentally ill were forgotten. In the 1980s, civil rights attorneys 
began filing class actions lawsuits to close down horrific state 
hospitals. They won a slew of precedent setting cases. The police 
could no longer arrest someone just because they were mentally ill; 
a psychotic person could not be locked indefinitely against their 
will in a hospital; they couldn't be forced to take medication or 
undergo forced treatments, such as electric shock or lobotomies. 
The U.S. Supreme Court ruled that the mentally ill were entitled to 
the same due process protections as suspects in criminal trials. 
Under pressure, Congress agreed to make the mentally ill eligible 
for Medicaid and Medicare, but only if they were not living in a 
state hospital. It was Congress then, that gave state legislators a 
way out.  Afraid of class action lawsuits and mounting public 
pressure to do something about the asylums, state legislators began 
boarding up mental hospitals and discharging patients. This 
massive exodus was called "deinstitutionalization."
     	And what happened to the mentally ill?
        In most states, patients were released without any effort being 
made to link them to community services - if, in fact, there were 
any. President Kennedy's promise of three billion dollars was a 
cruel lie. There were no network of community treatment centers 
and those that had been built were never intended to help deeply 
disturbed patients. Chronically mentally ill patients began 
appearing on street corners. By the 1990s, there were so many 
being locked up on minor charges that a word emerged: trans-
institutionalization, bureaucratize for the "transfer" of the mentally 
ill from hospitals into jails.
    	Like most states, Florida made no preparations before it began 
dumping patients. But eventually, it found homes for most in 
"assisted living facilities" - cheap hotels and boarding houses. 
Today, there are 4,500 mentally ill patients living in 650 "ALFs" 
in Miami. Almost 400 of these ALFs fail the state's minimum 
standards for boarding homes. They are unsanitary, unsafe, and, in 
most cases, wretched places. "I wouldn't put my dog in this 
house," a Miami police officer told me when we toured an ALF. 
But Florida allows these substandard homes to operate because 
there is no where else to house the mentally ill.
    	Florida's dreadful state mental hospitals had been closed by 
deinstitutionalization, but the lives of the mentally ill hadn't really 
gotten better. The state had simply scattered them and hidden them 
better in ALFs.
 	I decided to check the Washington D.C. metro area. Since 
1955, the District has lost 92 percent of its public mental hospital 
beds; Maryland has lost 86 percent, and Virginia: 84 percent. 
Although private hospitals have opened some wards, there are only 
98 beds for every 100,000 mentally ill people in the metro area, 
creating a staggering backlog. As in Florida, the number of 
mentally ill in local jails has mushroomed. Today, 2,551 inmates in 
Virginia state facilities are considered severely mentally ill. 
Another 3,330 prisoners in Maryland - fourteen percent of the 
state's inmate population - are mentally ill. And an whopping 33% 
of the District's inmate population require mental health services. 
                        *****     *****    *****
     	In a letter to the homeowners, our attorney said Mike would 
meet a much tougher set of restrictions if they would allow him to 
plead guilty to misdemeanors. Instead of serving a year of 
probation, he'd serve two. He'd stay in the day treatment program, 
continue seeing a psychiatrist after he was discharged, submit to 
blood tests to prove he was taking his bipolar medicine. Kersey 
would obtain a restraining order against Mike that would forbid 
him from coming near their home. He reminded them that Mike 
had a clean record, was truly remorseful, and that he'd chosen their 
house at random. "This should do it," he said confidently.
     	But a few weeks later, he received the couple's harshly-worded 
response. They wanted Mike in jail. They insisted he plead guilty 
to a felony. If anyone deserved sympathy, they added, it was them. 
      	"You need to prepare Mike," Kersey warned. "He's going 
to become a felon."
      	Mike was wearing his new suit again when we returned to 
court. Just before it was about to start, Kersey came rushing up.
       	The victims had telephoned the prosecutor's office the 
night before and asked for a continuance. The husband was out-of-
town on a business trip and the wife didn't want to come to court 
alone. But the prosecutor had turned them down. "If the wife isn't 
here, there's a chance the prosecutor will let your son plead to the 
two misdemeanors," Kersey said. He'd shown the prosecutor the 
list of additional restrictions that Mike was willing to accept. 
      	We stepped inside. Every time I heard the courtroom doors 
open behind me, I turned to see if it were the wife. The judge 
entered. The wife still hadn't. The clerk began to call the docket. 
When he reached Mike's case, I heard the door swing open and felt 
betrayed. I assumed she had been hiding, mustering her courage, 
but when I glanced around, it was a stranger. Still, none of us knew 
what if the prosecutor would accept our offer.
      	"Your honor," he said, "we have reached an agreement in 
this matter."
      	In fewer than three minutes, it was over. Mike had pleaded 
guilty to two misdemeanors and had been placed on two years of 
        As we left the courtroom, I thought about the wife. I had 
honestly come to despise her. But now, I wondered how I would 
have felt if I had come home and discovered a madman had broken 
through my plate glass patio door. How would I have reacted if 
he'd taken a bubble bath in my teenage daughter's tub? What if I 
had become so distraught that I had felt compelled to put my house 
on the market? Would I have acted like she had? Or, would I have 
showed compassion? Because it was Mike, the answer had seemed 
so obvious. But, sadly, when I stripped away his face and replaced 
it with the menacing look of a deranged stranger, I realized I might 
have reacted much as she had. I felt conflicted. The victims had not 
had the knowledge that I now had about mental illness. But I 
would not have had that information either had it not been for 
Mike's unexpected plight. I began to see the wife differently. I 
began to see her as the reader whom I most wanted to reach with 
my book, the audience that I most needed to persuade. I was also 
forced to realize that she truly was a victim. And it was Mike who 
had victimized her. I only hoped that someday she would come to 
see that Mike had been a victim too. 
                        *****     *****     *****
      	Mike kept the plea deal. He completed the day treatment 
program, stayed on his medication, and began looking for a job. 
He'd been told being mentally ill was nothing to be ashamed about 
because it was a chemical imbalance. But when he mentioned that 
he had bipolar disorder, his job applications were rejected. Mike 
had a college degree, but our neighborhood Giant food store turned 
him down for a job bagging groceries. A sympathetic human 
relations director told him not to be so forthcoming. "If I 
knowingly hire someone who is mentally ill and you end up 
hurting someone on the job, that person can sue me and the 
company. No one is going to hire you if you tell them the truth." 
Mental illness, we'd discovered, carried its own life sentence.
        A temp service finally found Mike menial work and he 
eventually became a full-time employee. Proud of his new 
independence, Mike invited me to lunch. We met at a steak house 
and sat outside because it was a warm afternoon. He had come a 
long way from that panicky day when we had raced to the hospital. 
Our food came and he recalled how I'd brought him fried chicken 
in the hospital. We talked again about the fishing story -- the one 
about him falling down a South Dakota cliff and me climbing 
down to rescue him.
     	I watched him eat his steak. He was a handsome man. Tests 
showed his IQ was higher than mine. I realized how fortunate we 
both had been. He had recovered. He hadn't spent time in jail or 
been marked for life as a felon. He was doing well on his 
medication. His bipolar disorder was in check.
        I thought about people whom I'd met in Miami while I was 
doing research inside and outside the jail. Judy Robinson's 
mentally ill son had been in-and-out of jail forty times. Another 
mother's son had lived homeless on the streets for nine years - 
despite her attempts to get him help. She had driven by him rooting 
through garbage cans every morning on her way to work and had 
been helpless under the law to intervene. How ironic, that the civil 
rights laws that had been passed to prevent the mentally ill from 
being abused in state hospitals were now being cited to keep them 
from getting help until they hurt themselves or someone else and 
ended up in jail. I'd met a woman in Miami the same age as Mike. 
Her mother had gone to court several times to force her into a 
hospital, but doctors had repeatedly discharged her because her life 
wasn't in imminent danger.  She had been twice gang raped while 
psychotic on Miami's mean streets. Another woman, Alice Ann 
Collyer, had shoved an elderly bystander at a bus stop during a 
delusional moment. Because she was considered dangerous, 
prosecutors had transferred her back-and-forth between the Miami 
jail and a state forensic hospital for three years just to keep her off 
the streets. Three years in jail without ever being convicted of a 
crime. Miami's treatment centers were overwhelmed and 
inadequate. Its system badly broken. As Dr. Poitier had warned, we 
had gone backward. We now treat the mentally ill in America just 
as we did in the 1830s when they sat in freezing jail cells put there 
because there is no where else for them to go.
        I had begun my research because I wanted to save my son. But 
I now realized that I had actually been searching for a way to save 
both of us. I had been trying to learn how a parent comes to accept 
his child's mental illness. So what had I learned, not as Pete Earley 
the reporter, but Pete Earley, the father? Several quiet truths. Life 
is often unfair and nothing in life is ever guaranteed. There was a 
slim chance Mike would never have a relapse. But there was a 
better chance that he would stop taking his medicine because he 
would become convinced that he no longer needed it. His illness 
was not over because I was writing the final chapter of my book.
        "You know what your problem is dad?" Mike said, as if he 
were reading my thoughts. "You worry too much. Just eat your 
steak and enjoy this lovely day." Everything is going to work out 
fine for me, you'll see."
        It was the blind optimism of youth talking. And yet, Mike was 
right. At that moment, everything was fine. My son was thinking 
clearly. He had a job, was making plans for his future, and seemed 
    	Which led me to another lesson. 
    	Mental illness is a cruel disease. No one knows who it might 
strike or why. There is no known cure. It lasts forever. My son 
Mike has it. And because he is sick, he will always be dancing on 
the edge of a cliff. I cannot keep him from falling. I cannot protect 
him from its viciousness. All I can do is stand next to him on that 
ravine, always ready to extend my hand. All I can do is to promise 
that I will never abandon him. 
     	I took a bite of my steak and it tasted better than any I had ever 
eaten. I understood why. The sun was warm on my face and I was 
a most fortunate man. I was a proud father. Mike was laughing. He 
was safe.  
I had my son back. At least for now.

        MR. DEAL.  I want to thank all of you for the very courageous 
testimony we have heard, very heart-wrenching, quite frankly.  
        Mr. Earley, as someone who has been a former juvenile court 
judge myself, I can empathize with the situation that a parent is in.  
Unfortunately, these diseases as we have heard from your 
testimony and as we have heard from the expert panel earlier, the 
onset many times is at the age beyond which the law says that they 
are independent and therefore not subject to the control of parents.  
Yet parents are the ones who feel the impact of these situations as 
you have so graphically described. 
        I guess I would ask some general questions of the three of you, 
and you come at this issue, quite frankly, from sort of different 
directions, one being the parent and the other two being the victims 
themselves or the individuals suffering from the problem. 
        Looking back on your situations, I suppose, Ms. Martin and 
Mr. Lamphere, what could have been done earlier in your personal 
situations that would have made a difference in the direction that 
your lives took?  Who and what would have been the resources 
that could have been that difference?  
        Very general question.  Ms. Martin, I will start with you. 
        MS. MARTIN.  I think the way I could have been most helped 
is, my family knew I was suffering from depression, but my Mom 
especially, having suffered from it herself, was of the attitude, you 
don't talk about it, you don't tell people about it, you keep it in the 
family, and you don't get help because therapy is for other people, 
therapy is for people who are weak, therapy is for people who are 
whiny.  If I had been aware of the benefits of treatment and had 
someone talk to me about how there shouldn't be a stigma with 
mental illness, it would have prompted me to get help a lot sooner 
instead of taking it to the point where I lost a job and I lost income 
and I lost a lot of self respect.  So I think just an initial almost an 
intervention of someone in my family who knew what was going 
on to say, you need to get help and you need to get it now and it is 
okay to get that help, it is okay to admit that you have a mental 
        MR. DEAL.  Mr. Lamphere, you appear to be the rugged 
individual here who tried to do it on your own.  Is that pretty much 
the course that you took of trying to do it yourself, and if not, what 
resources did you utilize?  
        MR. LAMPHERE.  My wife was right there until almost the very 
end.  I would say this, there are general practitioners who can 
dispense antidepressants, and then there are psychiatrists who can 
dispense them.  Then there are psychiatrists, who have depressive 
experience, and then there are psychopharmacologists, and then 
you begin to get into teaching level hospitals, and then you can get 
into real cutting-edge teaching. 
        This is so complicated, to find the right medicine.  You cannot 
just take Wellbutrin, I am not picking on Wellbutrin, off the shelf 
and think that that is going to work.  You can't just take Paxil next 
and think that this is going to work. 
        You are looking for a witch doctor is what you are looking for.  
You have got to get far down the line to someone who truly 
understands the combination of drugs that are apt to bring you up. 
        I think that is where I would have done it differently.  I don't 
think I would have started here and said, oh, these people are 
experts, or that the drugs are experts in and of themselves.  
        It is the utilization of the cocktail.  You are creating the 
cocktail, and you need to have the cutting-edge people.  
        On top of that, I would only add one other point.  The 
treatment of adolescents is a whole other area of specialization.  So 
what I am talking about is adult.  But don't forget, these age 
groups over here are real specialties.  If you are dealing with a son 
or a daughter in that age group, you have got to find the expert 
there, too. 
        MR. DEAL.  Mr. Earley.  
        MR. EARLEY.  Well, Mr. Chairman, when my son starts to 
become psychotic, he thinks he is fantastic.  Expecting someone 
with bipolar disorder or schizophrenia to treat themselves is like 
asking someone who has 2 broken legs to run a marathon.  The 
National Institute of Mental Health has done a number of studies 
that show that one of the first parts of the brain that starts to go 
bad, if you want to use that terminology, is the part that makes you 
aware that you need help, which is why it is so frustrating for 
parents and others who love mentally ill persons to try to get them 
help when they don't recognize they need it. 
        MR. DEAL.  I want to thank all of you. 
        Ms. Baldwin, you are recognized for questions.  
        MS. BALDWIN.  Thank you, Mr. Chairman.
        And thank you all for very powerful testimony.  You all point 
out so powerfully how important it is to educate. 
        Mr. Earley, I wanted to explore further one of the main issues 
that you had testified about, I remember when I was a State 
legislator, having our State legislature tackle the issue of what in 
Wisconsin we call the fifth standard, dealing with the issue of 
when you have a patient who does not want treatment, as you just 
described, under what circumstances treatment can be administered 
against that patient's will and direction. 
        And I remember that the debate was fascinating, and it is one 
that is usually governed at the State level, but I would be interested 
in hearing more about your thoughts of where you would like to 
see the State of Virginia go.  In Wisconsin, we ultimately created a 
fifth standard that you could get around the imminent risk of 
harming oneself or another person.  But I remember the very 
powerful testimony of a man whose wife was mentally ill, and it 
never manifested itself in any type of dangerous activity in terms 
of life-threatening to herself or to others.  But she wandered and 
was homeless, and it was just devastating for him to see her in that 
condition.  So dangerousness wasn't an element that would have 
necessarily gotten care to her.  I wonder if you have thoughts, 
through both Mike's experience and also your reporting on this, of 
where you believe the State ought to go in terms of getting greater 
access to treatment for people in your son's condition?  
        MR. EARLEY.  Thank you.  You know, I love my son.  I want to 
protect his civil rights.  But I don't think it does any of us any good 
to send someone out in his kind of condition when it is obvious he 
is not thinking clearly.  I think you have to take a look at why these 
stringent commitment laws were passed.  In the 1960s through the 
1980s, we had these horrific institutions.  They were absolutely 
horrible.  They were compared to Nazi concentration camps, and 
civil rights lawyers came in and basically said, we are going to 
make it impossible to commit someone to those horrible places.  
They have done that.  
        I don't believe we should trample civil rights, but I think we 
need to take another look at those laws and try to bring parents and 
doctors in and try to remove this imminent danger clause.  
Treatment today is different than it was.  We know more.  No one 
volunteers to be schizophrenic.  
        My son has been forced into a hospital twice.  Each time, it has 
been less than 2 weeks.  He got his medication.  He thanked me for 
taking him in.  You know, we have protections in place with 
advocacy funded by Congress to make sure people don't get 
abused and put away.  Does it happen?  Absolutely, look at the 
D.C. situation.  It is horrific.  People are being abused.  But, right 
now, people are being abused in jails and prisons.  Right now, in 
Miami, 4,500 people are being housed in assisted living slums by 
the State that don't even pass minimum standards.  So we have 
closed down these institutions, but we have just hidden the people 
        So I think we need to look at the commitment.  I think we need 
to be more humane about that.  I will be real brief here.  What you 
just mentioned is what I found in Miami:  455 people with serious 
mental illnesses, homeless on the street, most of them committed 
misdemeanors.  What happens?  Because they are not dangerous, 
they go into jail and are held, and they are released, 40, 50 times a 
year.  That is ridiculous. 
        MS. BALDWIN.  Let me ask your opinion on another innovation 
that I had heard discussed, I don't know of any location where this 
might actually be law, but there was at one point during our debate 
in Wisconsin the proposal of allowing somebody with a mental 
illness to essentially, when treated, issue an advanced directive and 
basically be able to say that, if at some point in the future I have a 
reoccurrence and I am not able to make my own decisions, at that 
point, use the advanced directive as permission to treat me.  
        Is that something that you think would be worthy of 
exploration?  Would that have served--would your son, for 
example, at a point in time when he is under treatment and feeling 
better, be willing to sign something like that?  
        MR. EARLEY.  You know, I have looked at that, and you have a 
mixed result.  In some States, they are not accepted, and in some 
States, what you will run into is a doctor like I ran into at a hospital 
that basically will turn to someone and say, you signed this, but 
how do you feel now?  They will say I am fine.  They won't abide 
by it.  So I looked into that in Virginia, and I found mixed results. 
        MS. BALDWIN.  Thank you.  
        Madam Chairman, I yield back.  
        MS. MYRICK.  [Presiding.]  I want to thank all of you again for 
coming and taking your time.
Mrs. Earley's birthday is today, and I want to thank you, say 
thank you, because she took time from her birthday to be here with 
us.  Thank you.  
        MR. RUSH.  I do have a question.  
        MS. MYRICK.  I am sorry, Mr. Rush, forgive me.  
        MR. RUSH.  That is quite all right.  
        Ms. Martin, you indicated in your testimony that one of your 
remedies or one of the things that you attempted to do, you found 
yourself falling into I guess you implied there was a use of 
narcotics or drugs, different type of drugs. 
        And I really feel as though that is a part of the drug problem 
across this Nation that doesn't get addressed.  Again, we are quick 
to criminalize those who have addictive behaviors rather than 
really try to understand what are the causes of it.  And in your 
testimony, you indicated that your mental condition, your illness, 
was the basis of your drug abuse; is that correct?  Could you 
elaborate somewhat on that, please, that particular aspect of it?  
        MS. MARTIN.  Certainly, certainly, Mr. Rush.  It was the basis 
of my drug problem.  I had never touched any kind of illegal drug 
until I was 22 years old.  I had just finished my first year in law 
school, and my depression that I kind of dealt with off and on and 
had issues with was getting stronger and was pushing more and 
more forward.  Suddenly, I had friends and I knew people who 
were using drugs.  I tried them for the first time and was happy for 
the first time ever.  I remember thinking, wow, this is amazing.  
Now I know why people do drugs. 
        For me, it wasn't that physical addiction that people talk about.  
When I stopped using drugs, I never went through a withdrawal or 
anything like that.  I did it completely as self-medication to feel 
        MR. RUSH.  I kind of think that that is--you know, I have a son 
who is a recovering alcoholic, and his diagnosis, manic, manic 
depressive.  And he invariably at certain points in time I think has 
been clean now for a couple, about 2, 2.5 years.  But, he was 
self-medicating through alcohol abuse.  And it seems to me that, 
particularly in poor communities, that it is much more prevalent 
when we, because they don't have access to preventative or 
diagnostic or clinical services and professional help, that that is a 
part of the problem in terms of drug abuse and also alcohol or 
alcohol abuse and using illegal drugs. 
        And it seems as though our Nation just doesn't want to look at 
that particular aspect.  Does anybody else have any comments you 
would like to share on that?  That is a hidden part.  Madam 
Chairman, that is a hidden part of what is missing here.  
        MS. MARTIN.  I think it is a hidden part, and to some extent, 
what you say about it being prevalent in the poor community 
because they don't have access is completely true, and therefore, 
they self-medicate that way.  Then if you get into a more affluent 
area of society, you see people like myself, I have several friends 
who did the same thing.  We didn't want to admit we were 
suffering, and we didn't want to go to a doctor and get help.  We 
didn't want to seek any kind of outside assistance, so we used 
drugs.  SSRIs work on the brain by stimulating serotonin and 
causing the brain to release serotonin.  That is exactly what ecstasy 
does.  Ecstasy floods your brain with serotonin, so taking an 
ecstasy pill, for me, was like overdosing on my antidepressant.  It 
was amazing.  People just say, you are just spoiled kids having a 
good time, or you are poor, you don't have adequate resources.  
Well, people really are missing that hidden side of drug abuse and 
alcohol abuse that is self-medication.  It makes us feel better. 
        MS. MYRICK.  Yield back?  
        MR. RUSH.  Yes. 
        MS. MYRICK.  Thank you.  You are right.  This is an issue we 
don't talk about.  Our granddaughter did the same thing.  I have a 
question about you, and I am glad you are talking about that issue, 
by the way.  I hope you will keep on doing that.  
        MS. MARTIN.  I will try. 
        MS. MYRICK.  My question was, what was the final straw?  I 
know you lost your job, but what was the final straw that made you 
say, I need to get help?  
        MS. MARTIN.  It actually wasn't losing my job.  I knew I was 
about to lose my job.  I had people in my office saying, what is the 
matter with you, you don't seem like you are enjoying yourself?  I 
was regularly asked if I was suffering from some sort of nasal 
condition because my nose ran a lot.  It finally kind of came to a 
head in the fall.  My grandmother had passed away, and what was 
pretty much just a weekend binge became an all-week obsession.  I 
had a very close friend who had suffered from depression and 
mental illness and was one of my drinking buddies for the longest 
time, and he finally came to me and said, you have to stop or 
something bad is going to happen, and you need to get help.  So 
that was the final straw.  When the person you drink with most of 
the time says you are drinking too much, then you kind of know 
you are in trouble. 
        MS. MYRICK.  It was an intervention by a friend. 
        MS. MARTIN.  It was, yes.  
        MS. MYRICK.  Thank goodness.  
        Mr. Lamphere, again, thank you for being here.  I was glad to 
heard you talk about this being a physical illness because, my point 
in this hearing has been this awareness issue of brain disease, and 
it is no different than heart disease and diabetes and all the other 
things that we deal with. 
        We seem to take our brain and put it over here on a shelf, and 
then here is our body over here, so please keep doing that. 
But was there anything in your life, going through this, that 
you would have done differently?  If you look back on it, is there 
any point where you would have realized, can you see anything 
now that would be helpful to other people possibly?  
        MR. LAMPHERE.  There is some interesting work being done in 
New York.  I think people have felt that depression always was the 
causative item of divorce, because of the extraordinary black 
vortex that sucks the spouse right in, and work being done on what 
is the middle ground that a spouse can take in that.  What is 
interesting, though, to answer your question is the research that is 
being done which is, did the marriage cause the depression to 
begin with, and the drinking or anything else behaviorally that 
started?  I think people might need to start thinking about that.  
That they have been depressed for prolonged periods of time and 
maybe self-medicating, and it has to do with the relationship rather 
than anything else that needs to be addressed that could be the 
causative item of the depression. 
        MS. MYRICK.  I appreciate that.  
        Mr. Earley, you have done a lot of research on the prison 
systems and the jails and the problem that government is paying 
for.  And I hope you will continue along those lines.  I have a son 
who works in that field, and he tells me continually, the percentage 
of people that are in prison who have a problem with their brain 
and drugs or alcohol, et cetera, has, gotten them here.  And I think 
we have got to face those tie-ins that we haven't looked at before 
as a society, because they are very real, and as Mr. Rush was 
saying, those are areas that sometimes we don't look at. 
        The frustration that you have experienced, I know is very 
difficult.  And the system is a mess from the standpoint of what 
you can do.  We have gone through that with our granddaughter.  
That is why it took us 6 years to get her diagnosed, because she 
wouldn't stay anywhere long enough, because the laws would say 
she could get out and up.  You could never get her diagnosed.  
Recommendations that you have, and I know we don't have time 
today, but anything that you can share with the committee and 
anything that we could do, as Ms. Baldwin was saying, that would 
help would be very beneficial because some of what we have done 
has caused the problem, and then you get all these jurisdictional 
problems in addition, and of course, we can't do a lot about that, 
but nevertheless, there are some things that maybe we could work 
on and you could be very helpful if you would be willing to work 
on that as well. 
        MR. EARLEY.  I appreciate that.  I think if you look at 
deinstitutionalization, the population that was in State mental 
hospitals, as it goes down, jails and prisons went up. 
        You know one of the quick answers, one of the quick fixes, 
every police department in this Nation should have a crisis 
intervention training program, CIT.  Fairfax should have one.  
None were available.  These are officers who are trained to deal 
with people with mental illness.  In Miami, the year I was there, 
the Miami police department, I saw them disarm a man with two 
knives without him getting hurt.  He later thanked them.  That 
same time period, the Miami-Dade Police Department killed five 
people with mental illnesses because they didn't know how to take 
care of them.  CIT, just like bomb squad, hostage rescue, every 
police department should have one of those. 
        MS. MYRICK.  Very good advice, again, thank you all very 
much for being here.  Are there further questions?  Chairman 
        Then that concludes our hearing for today.  Thank you.  We are 
        [Whereupon, at 1:20 p.m., the subcommittee was adjourned.]