Why We Need a Different Approach to Mental Health & Wellness with Dr. Tom Insel

good wolf. Thanks for joining us. Our guest on this episode is doctor Thomas Insel, an American neuroscientist, psychiatrist, entrepreneur, and author who led the National Institute of Mental Health from two thousand and two until twenty fifteen. Prior to becoming the director of NIMH, he was the founding director of the Center for Behavioral Neuroscience at Emory University in Atlanta, Georgia.

Tom also co founded Humanist Care, Neuroweal Therapeutics, and Mindsight News, and as a member of the scientific Advisory Board for Compass Pathways. Today, Tom and Eric discuss his book Healing Our Path from Mental Illness to Mental Health.

it's really about commerce. It's about a medical industry that I think does make sense in the care of cancer and heart disease and maybe diabetes, but it really doesn't work or doesn't deliver for people who have a range of emotional problem from the anxiety depression onto more serious mental illnesses like bipolar disorder or schizophrenia. And so my

concern is that we have built a system. Some people would say it's not a system, but we built a set of policies all to feed that particular wolf, and probably good for some payers, and it seems to be pretty good for the pharma industry, but it's really not that great for families, it's not that great for patients. It just hasn't worked out for us. So anyway, that was my first association with the two wolves.

inform a lot of this book. And I want to ask a question about that because you reference early on a pretty important moment where you realized that you had been helping guide policy towards a lot of money into research and development, and felt very optimistic about that and that that was the path forward. And then some things started to happen where you started to say, well, maybe that's not the whole picture. Can you share a little bit more about that?

federal government. It has its own laboratories and clinics, but it also about ninety percent of the money goes out the door to support academic scientists around the country, even around the world. And the basic mission is to try to figure out more about, in the case of this institute, mental illness, with the idea that we can do better on diagnosis and treatment going forward. So it's a bit

of a public health mission. As I say in the book, I was giving a presentation on much of the work that the Institute was doing, as well as the Obama Brain Initiative, which I helped to direct along with others. And it was a group of people I was talking to were mostly family members and advocates in the mental health space. And at the end, somebody got up and said, man, you just don't get it. You know, I have a

son who's twenty four years old. He's been hospitalized four or five times, been a couple of times, he's made it a couple suicide attempts, and he's currently homeless and we don't even know where he is. Our house is on fire, and you're telling us about the chemistry and the paint. And that was kind of a seminal moment that was a bit of an epiphany for me where

I had to say WHOA. On the one hand, I was defensive, but I had to recognize that he had a point, that the needs for mental health care had become urgent, and actually we had good things to offer based on all the science that had been done, based on the work of places like NIMH. So we had a lot to offer, and it wasn't getting out there. And I began to ask myself, how much more of my time do I want to spend on the research and discovery side. I think saying it's the chemistry the

paint is pejorative. I actually think we need to understand the chemistry of the paint. And I think there's a lot of hope and a lot of promise coming from science. But at some point you have to be accountable. At some point you have to say, you know, we've spent a lot of money, We've done a lot of science, We've written a lot of great papers, we have some interesting insights and even products to offer. Why aren't they getting out there? Why aren't we actually having a public

health impact? And what does it take to make that happen? And that was the moment where I started to say, well, maybe the academic scientific community is not the community to do that. I mean, they have teed up some great things to offer, but we've got to find a way

to get it out there. That's when I left for Google, thinking that working at that point in twenty fifteen, working with the largest marketing company in the world really, which was Google and through Google Search in Google Ads, that maybe there would be an opportunity to actually have a bigger impact than what we were able to do through the academic research.

And so while we could continue to improve vaccines and should, if they're not getting to people in a way that's actually helpful, that seems to be a pretty important place to focus.

I think it's super relevant to the question about psych piatric or psychological treatments we have. Like, for instance, while I was an IMH, we did a lot to focus on anorexia because it's one of the most fatal psychiatric disorders, and I'm proud to say I think we funded the development of some really significant advances. But even now a decade later, there's just a handful of people who are

trained to do those psychological interventions on teenagers with anorexia. Fortunately, that's a theme that's been picked up by a startup that's actually grown very quickly. It's probably delivered more of the bespoke therapy that we know works to more people with better results than we could have ever done in a brick and mortar, one by one clinic. So there is hope, and I do think that there are ways to scale what we want to deliver through technology, but

it's been a slow burn. It hasn't happen as quickly as I'd hoped.

then you get a diagnosis. So mental illness is medical, tends to be constrained by these diagnostic categories, and serious mental illness is nothing more than the deep end of the pool. It's those people who have that group of illnesses like schizophrenia, bipolar disorder, schizoaffective disorder which is kind of a mix, sometimes severe depression or severe PTSD, those disorders that cause enough disability to put you in that deep end of the pool. That is, people who are

not able to function because of their mental illness. We think they're about fourteen maybe fifteen million people who meet the definition of serious mental illness. The number of people who meet some criteria for some mental illness is in a forty to fifty million range in the United States, and of course many of those have something that's fairly minorus. You know, having a spiderphobia would be a mental illness, but it doesn't really lead to you being very disabled

in most cases. One other I think really important distinction to make while we're talking about language is that when we talk about health or mental health, pretty quickly we

start talking about health care and mental health care. And I think it's an important moment to say, hold on health is not just healthcare, right that if you look at what predicts health, what are the determinants of health, healthcare is one of them, but it's maybe ten, maybe twenty percent of ultimate determinants of what gives you longevity, what gives you well being. So health is something quite different. Has a lot more to do with where you live,

who you live, with, how what you live for. All of those things are much stronger predictors of health outcomes than your health care. I think that's the distinction we often overlook in the United States when we quickly start talking about healthcare. When we want to really be talking about health.

we can define, something we can work towards. Not actually clear that much of what leads to recovery is within the healthcare system or it gets reimbursed with healthcare dollars. We can unpackt this a little further, but you know, I'm pretty invested in this issue right now because it feels to me that in a country that's spending four point three trillion dollars on healthcare. Those agencies that are focused on recovery shouldn't just be existing on bake sales

and galas right. What they do, which is so significant for health you know, delivering recovery services ought to be considered like a really significant part of healthcare because they are really delivering health outcomes, and yet they're largely nonprofits. They may be staffed by volunteers. It's kind of weird

to me. In the mental health space, when we're talking about recovery, we're talking about sort of nonprofit, community based organizations often that are struggling just to keep operations going. Whereas you know, in this kind of adjacent or peril universe of medical care, if someone's on dialysis where they're having to recover from chronic renal disease, the another actually get to recovery until they get a transplant. But nobody

expects dialysis to be paid for through bake sales. And nobody expects that if you're even getting physical therapy after a car accident, that that's something that doesn't get supported.

As you recover your physical capability, that that's of course going to get paid for through health insurance, and yet recovery on the psychological side, on the behavioral side, it's somehow considered qualitatively different that you leave that to volunteers, you leave that to the world of community based nonprofits. I don't get that, and I don't think we should accept that necessarily. So I've been thinking a lot about that double standard.

they can go to recovery meetings. That all these things make it more likely that somebody's going to get sober and stay sober. Doesn't mean everybody who gets those things will, and it doesn't mean that people who don't get those things won't, but it just makes it a whole lot more likely and a whole lot easier. And I think the same things you're saying sort of apply to our mental health. Right to embark on a healing journey is to need a certain degree of support, at least early

on for a little while. And that support is not just a therapist, right, It is how do I get back into the workplace so that I can make a living and feel good about myself? How do I have friends who understand me? And I mean that all these elements go into it so I do think that we need a lot more focus there. I do think it gets a little trick when these small scale organizations that seem to work so well on bake sales become bigger and well funded. Things get a little weird. You know.

One of the things that Alcoholics Anonymous did well, now lots of things I think could be different, but was that they remained forever non professional. They kept a certain element of people putting a dollar in a basket is the way the organization function, and that gave it a certain independence and a certain community.

to this idea that was not my own. It came to me through John Sharon, a psychiatrist in Los Angeles, who was saying that recovery is really the three piece that you need, all three p's to go on this journey. And he wasn't talking about necessarily recovery from addiction, but any kind of recovery. And Eric your point about remembering that recovery isn't really going back to where you were,

it's more becoming something that you haven't been. His idea was that it was people, place, and purpose that you need social support. You do need a group of people around you who have your back, and by the way, you have theirs as well. So this sense of community incredibly important and very very powerful. It's one of the ways that AA is so effective. You need a place and that means an environment that free of all the triggers, but also an environment that is nurturing and allows you

to grow and to change. And then I think the third P, which is the one that we never talk about but is probably in some ways the most critical, is you need a purpose. You need a mission, You need something to wake up for every day. You need something to sacrifice for and to give yourself to something bigger than you. That third pe is almost never in

the conversation around healthcare, and yet it is fundamental. I mean, in the book, I go back to this idea from years and years and years ago of logo therapy, the idea that the person who has a why can live with anyhow that's right. That's a really useful mantra, useful concept, but one that you don't hear much about in the traditional healthcare journey. Is just not something that people get to right.

any other sort of variety of behavior problems. But I can look back and I can see it from even being a small child, you know, like when I was in trouble and when I wasn't and it was all about that purpose.

how that took off, particularly amongst university students. So we have a fair amount of activity at you see Berkeley here in the Bay Area and asking students where the value of this is because it's really connected to the counseling center at Berkeley. And the idea was to give students something quickly so they weren't on a long waiting list. And what we found was that the real value wasn't just what students got, it was what they were able to give. That was the most therapeutic part of this.

And you know it's the piece that again, healthcare as we know it never goes there. It's just not a part of what you get when you go to see your primary care doctor. They don't ask you, so, who are you helping today? I'm helping you, but I who are you helping as part of this? And how do you pass it on? So it's really, I think, a different approach, a different formulation, but a tremendous opportunity to

change what we do. And it's all in this kind of spirit of helping people to recover or at least to be able to function in a way that's to them closer to this mental health idea of being able to love and to work.

in a bite sized, short and simple manner. We've heard from listeners that these texts help them take a moment to reconnect with what's important amidst the busyness of daily life. Someone said it feels like a little bit of wisdom is being whispered into my psyche, which I thought was cool. So if you'd like to hear from us a few times a week via text, go to one ufeed dot net slash text and sign.

But you were initially skeptical of this model because you're a believer that there are evidence based things that work, and then there are other things, and that getting the right type of care to people is really important, and that's one of the things AA has the peer piece figured out very well, But there is almost no innovation in what we know, more of the modern ideas, more of the evidence based theories about what works.

of gone in a couple of different directions. With this one I think is that to realize that the real problem we face on the mental health population wise is not so much on the world of caregivers. It's in the world of what people experience who should and could be in care. And this is true for serious mental illness. It's probably true for people who have less serious forms. But the reality is that we have good stuff to offer, but only a tiny fraction of people who could and

should benefit or getting care. And the reasons for that are not so much that they don't get access. Yeah, there's a bit of that. I mean, there's a supply demand problem. I get it. I think that's always been true. It's much worse now. But there's another side to it, which is that for a range of reasons, people do not seek care who should. And the problem for me

isn't so much access, it's engagement. How do you engage those people it would really benefit, so that you get to them before they're in a crisis, before they're suicidal, before they're in the emergency room, and before you're actually ending up in this kind of medical system which isn't really incentivized towards helping you in the way that does have the continuity and the recovery focus and all the things we've been talking about. That engagement piece is done

by peers better than anybody else. That is where you can begin to solve for the population health problem the seventy percent of people or sixty percent of people who are outside of care. And I think peers have a lot to offer there. I don't think they're the full answer, because you still need to be able to get the highest quality interventions, which may require someone who's had twenty

years of experience. And often what happens with peers as committed as they are and as passionate as they are, you know, their education is largely in the end of one They have their experience and sometimes is right, sometimes it's not right, and so there's real value there. The other thing we have to be honest about is that asking peers to do some of the heaviest lifting years also exposing them to a range of triggers that probably not necessarily in their best interest, and so you have

to be mindful of what works what doesn't. I do think engagement say it's something that peers do well. I think they're part of a larger army of people that would include community health workers, people who have lived experience in their families, people who may have just been really interested in being in the community and being able to meet people where they are rather than waiting for someone to show up at a clinic. So I think we

need all of that. And if we are going to involve peers in the workforce, and I certainly hope that we do, I think we need to. If we're going to be successful, we have to pay them well. We have to professionalize this, and we have to make sure that yes, they're not simply token in some way, or they're not there simply to fill some kind of quota, but that they're given real jobs with real responsibilities and paid accordingly. And I don't see that happening everywhere.

maybe better in many cases than credential therapists. And I was giving a talk about the need for us to have evidence based treatments in every part of what we do in the mental health care space, and somebody got up afterwards and said, you know, you've got to remember that the therapist this is important as a therapy. It really ultimately comes down to having the right person, not

necessarily the right brand of therapy. And you know, he went on to say, you know that he was a scientist and even looking at this for a long time, and I started to dig into this literature a little bit. It goes all the way back to Healing and Persuasion

by Jerome Frank back in the nineteen sixties. Because it's so relevant now, But that was Jerome Frank's important insight at a point when people were very focused on the psychoanalysis and doing it in a very precisely technical way, showing that hey, you know, what really mattered was the person and their relatedlationship that they built, and not so much whether they followed precise rules of how this therapy

was supposed to be delivered. There's an important lesson in that, something that we need to remember even today, that it's what you bring to this experience, into this relationship that's probably as valuable as whatever particular credentialing of whatever particular brand of treatment you've been trained to do. You can go too far in that direction, but I need to keep an open mind that people bring lots of things to the table, and not all of it is exactly their.

of a crisis. But that's been my experience, is that I've had to try a variety of different things and sort of piece some different things together and ultimately find like, Okay, this is the combination of things that really works best for me.

There's this whole movement called precision psychiatry or precision mental health, which is still maybe a little bit in its infancy, but I think has enormous promise to help get beyond trial and error and to put together different kinds of information in a way that allows us to get somewhat better.

At the end of the day. I still think relationship matters, but at least to get to a point where you're able to say if medication is indicated, which medication, psychotherapy is indicated, which psycho therapy, and then to understand who can deliver that in a way that works best for you. I don't think that's that far into the future. There are groups doing this now and bringing together multiple predictors.

I think the lesson that we have over the last four or five years is that there's no magic bullet. It's not like genetics or imaging are going to sort of answer those questions like where the science is right now. It says that if you bring together cognitive testing eeg.

Some work on actually accounting for symptoms, and then some sensor data on sleep and on activity and your patterns, we can begin to triangulate all of that to get an understanding of what might be most helpful on the medical site, to say, oh, you've got a version of depression or PTSD that's going to respond best to X, Y or Z, and also in some cases insight that says, actually, you know what, the kind of depression you have responds far better to this version of psychotherapy that it will

to any medication. I mean, I think we can do that today, for many many people, it's not being done. We don't again back to your original question, Eric about the wolves, we're not incentivized to do that. That day

is coming. I think there'll be a moment when the way in which our field will be reimbursed and supported will require that kind of rigor and that kind of outcome driven approach that says, you know, if you're a provider, you'll get paid based on how much good you're doing, not on how many hours you're spending, and't wait.

Maybe that sort of helped, But what if I increase

the dose? Well maybe, But so I think that if we can get closer to that, I think that's a really big deal to be able to get a little bit more targeted in those Now I want to pivot off of that question because I think it goes a different direction than I wanted to try and go with you for a second, which is that there seems to be more of a movement that I've been hearing about and detecting that is starting to say that the DSM is not a really useful tool in certain ways, and

that trying to segment these different things apart from each other might be missing an underlying common factor. Right. I think there were studies that showed maybe there's a P factor that underlies mental illness, and the people who talk about that say the reason that they come to that conclusion is two things. And I would really love your

thoughts on this one. Is comorbidity, right, Like, if you have depression, you're likely to have anxiety, and you're also more likely to have this and that, and you end up with five diagnoses and you kind of go, well, am I really that unfortunate that I got all five of these?

So you could imagine two people walking in who had five of the nine but only overlapped on one, so had one out of nine they shared, and yet they had the same label. If this didn't make a lot of sense. Furthermore, you'd see the same person over time and it would be, as you say, every time you'd see them, that'd be a slightly different pattern. And so you just had the sense that, as somebody said to me, we weren't cutting nature at the joints. It wasn't really

capturing the fundamentals. We started a project that was then called the Research Domain Criteria Project. Our doc very controversial at the time, but we basically said, look for research.

DSM isn't working, and the reason it's not working is because we're funding people to do ile markers of depression and they go out and they measure something in spinal fluid or blood or they do a brain scan, and everybody with major depressant disorder as defined by DSM, and they only see the finding in fifty percent, so they decide it's not useful. And our response was to say, nonsense. Maybe you start there on everybody who has the same

brain scan and you work from there. Instead of throwing that way and saying, oh, it has to obey exactly what the APA suggests is ground truth. We just didn't think we had really anybody had really established ground truth.

and cancer. You know, previously cancer diagnosis had been based on gross pathology, and you grouped everybody together based on that, and then you discovered when we got into genetics that wow, that didn't work at all, that what really mattered was identifying the molecular lesion because that would determine who would respond to which treatment, and you'd find the same molecular

lesion in tumors that look grossly, very very different. So we began to realize in cancer diagnosis that wow, we can't really use just the observations we have to have genetics and mental health genetics itself doesn't really seem to work that well. It might work for autism, but it doesn't seem to work so much in current areas that we look at. They just aren't kind of specific lesions

the way you have them in cancer. But there are other things we can begin to use, and I mentioned them before, approaches like EEG and cognitive testing, and I think there's a lot we can do just to understand behavior better. Beginning to look not only at sleep where you actually measure sleep, but looking at activity and looking at voice and speech and how all those things are changing, we can begin to provide much more objective data about

mood and anxiety and cognition and psychosis. I mean, all of that. We can do far more precisely than what we've been doing. And with that, I think we can start to rebuild how we think about the labels that we need in this field. Really interesting set of studies by guy at Harvard, John Weiss, who I think is worth reading. I talk about him in my book, and John is just focusing on children in particular, and he sort of just does away with all these type nut things.

It says, look, there are just really five things in kids that you want to be able to understand in terms of dimensions of behavior, and each of them has its own intervention that you need. And I read that it all became just much simpler, and I actually think that probably where we need to go is not we're now what at three hundred and fifty or something like that, three hundred and sixty labels in DSM. Maybe we need ten,

maybe we need five. I don't know, but I think, you know, what John Weiss has done for kids is actually a very interesting project that something like that might help to inform what we do more broadly in adults. I think our doc itself was an interesting way of sort of trying to turn the herd, trying to move the research community in a different direction. It was never meant to be a clinical tool, but the hope was that it would begin to inform whatever DSM six becomes,

and we'll have to see whether that happens. I do think to go back to your original question, Eric, is we had to do a better job of thinking about what to diagnose us for and how do we use it, because at this point, you know what really accounts I think is treatment, it's interventions, and it's not helping us and choosing interventions for the most part. And I think that was really the problem with our doc. It was never really tied to treatment response. It wasn't intended for that.

But ultimately, you want to be in a world where you are collecting information about how people think, how they feel, how they behave, and using that to provide interventions that help them to get from where they are to where they want to be. They haven't done that. I don't think DSM does that. I don't think our doctor has yet done that, And I think we have to get maybe much simpler if we want to be able to accomplish that. But I'm not sure I know how to do that yet.

more precise and specific in precision medicine. We're actually going even deeper than these different clusters of syndromes, and we're really narrowing into Eric right, what's going on with Eric right? And at the same time, we're also talking about maybe simplifying some of the overall models so that they make more sense with what's happening. So it sort of sounds like, in your mind, it's sort of both, right, let's get simpler in certain ways, but in other ways, we're actually saying,

let's get even more specific. Let's go beyond going from let's say there's five hundred diagnoses in DSM, and instead of going to seven hundred and fifty diagnoses, right, we actually go to Eric. Yeah, And we're precise enough to say we don't even necessarily have to give it a name, but we know, based on what's going on with Eric here, the interventions that we think are going to be most likely to be helpful.

morbidity from cancer. Pretty dark cool. We don't know how to do that yet for depression or anxiety disorders or psychotic disorders, but my goodness, as you said before, Eric, I mean, they're incredibly heterogeneous. At the end of the day. What you really care about is what can we do for one person at a time, what really makes sense, And so I would agree with you. We want to both make it simpler, but we also want to make it very individual, and understanding how to do that will

be important. We also want to kind of empower people to help themselves in ways that we haven't had, and I think that in some ways is very different than the cancer model. So the cancer model really comes out of the medical approach that if we can just get smart enough, our experts will figure this out. What I want to suggest here is this is not the same.

It's a different set of problems and that people place in purpose, creating community, creating environments, creating purpose, which is really the essence of what we're going to need for recovery. There is no single magic bullet. There's not going to be a genetic finding that gets you there. It really requires a different way of thinking about the problem and a different orientation to solutions. The solutions that are much more social than medical. And I'm not sure we've quite

grasped that as a field. And that's not to say I mean I often try to get away from these dichotomies and the way I've tried to resolve this one, and I struggle with this in the book, and I kind of finally end up this way is to say, I think that we can define the problem as medical, but the solutions are going to be social, environmental, even political. I wouldn't say that about breast cancer or hypertension. I think, you know, the problem is medical, and the solutions are

mostly coming up with the right medical intervention. Here, I think the problem can be defined as medical. I think there's fundamentally, particularly for people with serious mental illness, you're talking about something in the brainers or people with addiction, it's now a brain disorder. But those solutions are going to require something very different than what we do in

the rest of medicine. I think it's a particular challenge for us to figure out how do we do that, who does that, how do we pay for that, how

do we make it happen? And that's where I think the book kind of goes into asking for a radical rethinking and actually a new social movement, kind of like a civil rights movement, to say, we're in the Jim Crow era here that people with serious mental illness end up incarcerated or homeless instead of in treatment, and the treatments that they get when they do get treatment is so coercive and so ineffective. We have good stuff to offer,

they don't get it. How do we turn that around, and how do we make sure that those fourteen or so million people who currently are mostly found in the criminal justice system are to use. President Kennedy's original comment about this in nineteen sixty three said they must no longer be alien to our affections. That's Our challenge is figuring out how to make sure that this group of people who have become so disaffected and so disenfranchised by us,

to be really clear, they're really marginalized. How do we take them into our hearts and start to provide people place and purpose to allow them to recover. That's to me a massive social movement that needs to be undertaken and needs to happen yesterday.

all around it. But when you look at it, one of the things that becomes difficult to say, well, I've.

I also think with SMI, it's important that we should mention we've been talking about the three p's, but in no way, shape or form are you saying that medicine and the psychiatric drugs that we have they have a place, and they have a purpose, and they can really be beneficial. So we're not saying the three piece at the exclusion of those. I just want to clarify that what you're saying is we may be delivering some of the medicines

well enough, but probably not. But on top of it, we also need to be looking at this other element. When those things are delivered, they're delivered very fragmented from each other.

tolerate it for most other human problems. You want people to get access to as many things as possible, and I think some of it comes about because it's more about us as providers than it is about the people who we should be trying to serve. And if you see it from the consumer point of view, it's like what's best for me, and it's often not one thing, it's a combination of things, and very often that's just

not possible to do. They end up with a primary care doctor who's going to write them a prescription for an SSRI, or they end up in psychotherapy with a social worker who's going to spend a lot of time exploring their past trauma. It just feels to me like someone needs to knock down that divide so that you get access to both when you need it.

is more valuable than the other? I couldn't begin to tell you at this point because they've become so intermixed over the years. But I wouldn't want to try without one of them. I wouldn't like to just jettison one of them, be like, well, let's see what happens. You know, I found something that works for me. And I do think that this polarization is not helpful because it leads people to either only depend on medicine or not take medicine at all. And the answer is far more nuanced.

We just don't happen to be a culture that's very into nuanced conversation.

can engage with. And you know, one of the things that's happened during the pandemic is we now have literally hundreds of different online services, some of which are very good and are trying to do kind of what AA does, but doing it in a way that's far more convenient. I think there are plenty of opportunities to get help in a way that works for you. And that's the great thing now is you don't necessarily have to wait three and a half months on a waiting list to

see a therapist. You can probably find someone, or you can choose amongst thousands of people who would be available online through one of the current therapy or medication companies.

you then wrap up. You talk about something you call the pro doome, meaning that before somebody develops severe psychosis, right, there's often a multi year period where behavior is beginning to change. There are things we know to look for, and that early intervention makes a lot of sense. Now I think this is common sense. Maybe it's not common sense, maybe it is just to me, I think that's a

really important point. My question is more around similar to alcoholism or addiction, and this is starting to change a little bit. But things have to get to a certain level of bad before people are willing to do a whole lot about it. So do you have any insight into how to get people to help sooner before it becomes a crisis, Any thoughts on that?

So many people between the ages of fifteen and twenty five, or if you go three years earlier, between the ages of twelve and twenty two, you know they're experiencing a lot of emotional chaos. That is what adolescence is all about. So knowing which one of those people is will go on to hearing voices and becoming delusional is hard to

really to predict. We're learning more, and the thought had been that, well, maybe there'll be some biological factor that will help us predict and there are some pretty good signs. I think the science there is interesting, but none of its scales to allow you to do this for a

whole population. So we're still, i'd say, trying to figure this out whether you could do the same thing for you know, when does social drinking become alcoholism, When does the use of any addictive compound begin to become a problem? I'm not sure sure we've thought is well about that, and it may have to do more with not what you use, but how you use it and whether, as my colleague ATNIDA used to say, when it goes from being something that you'd like to something that you need.

That's really the transition, and that happens in various ways. It's so interesting to me that it's not a function of how much somebody uses the substance, but how that substance uses them and how it changes what they do, and that dependence is really often dictated by lots of things that are not just about the pharmacology of the compound or the biology of the person, but other factors.

under control, I don't know. I do think that one of the lessons generally is that the earlier you can detect and the earlier you can intervene, the better the outcomes. And that just seems to be a fundamental truth across all disorders in medicine. No less true here, but we're not very good at that. We tend to get involved in the late innings when we're already a few runs behind. It's really hard to win the game under those circumstances.