01 Mar

Mapping the Brain: What about using the information we do have now to help people who are depressed?

March 1, 2013

On February 12, President Obama announced a broad, and very expensive (300 billion dollars), initiative aimed at mapping the human brain. He compared its importance, and benefits, to the human genome project, which he says returned $140 to date for every dollar spent, and has made invaluable contributions to medical science. Yet the neuroscience community itself is skeptical about the value of this kind of huge project, urging instead that we start smaller, literally, using very small animal brains and working our way up to the human brain. Neuroscientists themselves are well aware of the limitations of MRI images, and frequently note that much of the specific information we have about where certain activities are controlled in the brain come from open-skull surgery.

On February 25, 2013, the New York Times reported that “Many neuroscientists are skeptical that a multiyear, multibillion dollar effort to unlock the brain’s mysteries will succeed. “I believe the scientific paradigm underlying this mapping project is, at best, out of date and at worst, simply wrong,” said Donald G. Stein, a neurologist at the Emory University School of Medicine in Atlanta. “The search for a road map of stable, neural pathways that can represent brain functions is futile.”

Although I have incorporated neuroscience into my own work on psychoanalysis and psychotherapy, I am very aware of its limitations, particularly any attempts to physically locate specific activities in the brain, let alone manipulate them. Part of my enthusiasm about neuroscience is that it has contributed to the literature demonstrating that psychotherapy is better for treating depression than drugs or, in most cases, even antidepressant medication and psychotherapy combined, and also informs us that the brain remains plastic (able to change) well into mature adulthood and even old age. Broad levels of general activity can be seen in imaging studies, and before-and-after images have provided us with information about depression.

Neuroscience has also helped inform our psychotherapy techniques, noting that the brain works best with a steady flow of controlled emotion, rather than through eliminating emotion in favor of logic. This helps therapists understand, and implement, the notion of emotional engagement for optimizing mental health treatment outcome. There are many other research results that serve to enhance the therapeutic endeavor. But even those of us who are most enthusiastic about neuroscience understand the limitations of imaging technology, not to mention the fact that the brain has long been known to be highly adaptive in transferring functions to other parts of itself following injury.

Even the highly-popularized notion of intellectual activities and logic being in the realm of the left brain and intuition and emotion lying squarely in the realm of the right brain have been challenged. Neuropsychiatrist Ian McGilchrist in his fascinating book on the brain, The Master and His Emissary : The Divided Brain and the Making of the Western World (2009), urges his readers to appreciate that while left or right brain hemispheres might be dominant for certain activities, both hemispheres are actively at work in everything we do, consciously and unconsciously. Understanding the brain cannot be adequately compared to the genome project, and, given the limitations of our ability to observe what is going on in the brain, is unlikely to produce any cures for Alzheimer’s or Parkinson’s any time soon, according to neurologists and neuroscientists.

Part of what excites us so much about neuroscience is that the brain remains a mystery. I am not saying we should not pursue further brain study, but rather I would like to see us spending less on this questionable effort and instead provide mental health benefits. That way the information we do have can actually be used to help people in need.

Last year a Federal parity law was enacted, requiring third-party payers to apply the same standards for payment of mental health care as physical health care. Having been given a year to “adapt” to this new law, most insurance companies responded not by increasing mental health coverage, but by restricting payment to out-of-network providers of physical health care and encouraging companies to raise their deductibles for their employees. By the time these high deductibles are met, most of the year is over and the patient has had to pay the bulk of the costs out of pocket. This has severely restricted the number of people who can afford weekly psychotherapy in spite of the great need and the evidence for its efficacy.

In a 2009 issue of the academic journal Neuropsychoanalysis, responding to an article about separation anxiety and depression, Dr. Paul Holtzheimer said, “As a practicing psychiatrist (specializing in medical management of patients with treatment-resistant depression) I also strongly agree that psychotherapy (including behavioral, cognitive, and psychodynamic approaches) is an extremely important antidepressant therapy that should be recommended for most, if not all, depressed patients.” He goes on to say that he disagrees with the authors of the article who claim that “Big Pharma” is responsible for the over-emphasis on neuro-biological cures for depression and says, “—rather, I think the inequity in mental health coverage by third-party payers, especially for psychotherapy has played a much larger role.”

Even when campaigning for his own health-care package, President Obama did not mention the mental health crisis in this country. In spite of record emergency room visits for both children and adults presenting with either severe mental health symptoms, suicide attempts, or drug overdoses, there is almost no national discussion of our dire mental health crisis, fueled largely by the closing of free clinics and the draconian cuts in mental health benefits. (The exception is the recent, and no doubt short-lived, outcry to keep guns out of the hands of dangerous persons who are psychotic.)

By all means, let’s fund more research for disabling brain diseases (my own father suffered from Alzheimer’s the last nine years of his life), particularly as our bodies continue to remain viable longer than our brains. But let’s not devote 300 million dollars a year to a project we are not equipped to implement at this point in time. The Obama administration has passed legislation that mandates insurance for everyone. It is time to implement what the psychotherapy research has demonstrated (including imaging studies of the brain)—that psychotherapy works and the next large-scale mandate should be mental health benefits for everyone that actually provide for weekly treatment.

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