For too long, mental health has been a policy and ethical backwater. While mountains of articles have been written on the ethics of cloning human beings (hugely unlikely to happen anytime soon), the morality of using genetically engineered animals as sources of organs for transplants (ditto), and the moral defensibility of using treatments derived from embryonic stem-cell research to cure horrific diseases (a very long shot), hardly any literature exists on the ethics of current practices and policies in mental health.
All that is about to change. A technological revolution imminent in mental health will soon revolutionize how mental illness is widely perceived and elevate it to the forefront of health policy.
We have all heard, perhaps to the point of indifference, about the mapping of the human genome. With dramatic technological advances, we have jumped from having a rudimentary chromosomal map of our genes and those of other animals and plants to a finely tuned, high resolution blueprint of human DNA. Think of the transformation from a basic map of the world's continents and oceans to the ability to locate your own front yard through satellite imagery on Google Earth, and you'll begin to understand the enormity.
Most of the discussion about the benefits of mapping the human genome has focused on diagnosing physical disorders or the risk of acquiring them. Breast cancer, heart disease, deafness, cystic fibrosis, Fanconi's anemia, hemophilia, and similar maladies have been the poster children in the emerging era of precision genetic testing. But, as genomic knowledge expands and as more databases involving all aspects of the health of millions of people are correlated with an ever-increasing number of genes, mental illnesses will surely be the newest targets for genetic testing. This means that embryos, fetuses, children, and adults will soon be candidates for testing for a vast range of risks and predispositions: addiction, depression, anxiety, schizophrenia, phobias, paranoia, obsessive-compulsive disease, aggressive behavior, attention deficit disorders, and many other mental impairments. Doctors will soon be able to detect the risk of developing mental illnesses as accurately as they now detect many physical illnesses.
The expansion of genomics into mental health will bring much good in the form of prevention and early diagnosis. It will also bring much controversy. Among the many thorny questions to be answered: Should genetic testing for risks of developing mental diseases be entirely voluntary? How private should such tests be? How much counseling ought to accompany the tests, and who should do the counseling? How accurate must these tests be before being made available to doctors, employers, or to the public directly in home-test kits? And, critically, what exactly constitutes a "mental illness" for which testing would be worthwhile in the first place?
This is not the stuff of science fiction. At least one company, San Diego-based Psynomics, is offering a home-test kit for a gene associated with bipolar disease and depression. A buyer spits in a cup and sends the sample off to Psynomics for testing. It is not at all clear that the test is accurate enough to justify its widespread use. Nor are doctors ready to explain the results of the test to those who buy these kits. Nor is it clear how to protect someone from having their saliva taken and sent off without their permission -- say by someone who swabs your mouth while you sleep or takes some of your DNA off a coffee cup or glass.
Right along with the explosion in knowledge about the genetic contribution to mental illness is another new and powerful, if less attention-grabbing, technology -- neuroimaging. We have all seen the fascinating pictures of how our brains "light up" in response to certain stimuli or thought patterns. Scanning technologies far more powerful than the familiar CAT scan -- tests like positron emission tomography, functional magnetic resonance imaging, multichannel electroencephalography, and near infrared spectroscopic imaging -- already make it possible to "watch" neural activity in real time with impressive accuracy. Since the link between the brain and your behavior is a lot closer than it is between your genes and your behavior, imaging the brain through these and other technological advances is likely to prove to be the biggest boon ever to the mental-health field.
Long before symptoms actually appear, a brain scan may reveal early onset Alzheimer's, anti-social tendencies, or autism; show patterns predictive of depression or suicidal ideation later in life; or prove predictive of who will find themselves getting into trouble in junior high school. Conditions that are now difficult to diagnose, such as mild schizophrenia or Asperger's, may prove easily detected when imaging results confirm suspicions.
Where is neuroimaging taking us? Want to claim that you need extra time on an exam due to a learning disability? You may need to undergo a neuroimaging exam to confirm your diagnosis. Hope to convince a parole board that you are ready to be discharged from prison after having undergone extensive therapy for child molestation? An intensive brain examination taken while you are exposed to suggestive photos may prove your case and secure a release sooner than a therapist's diagnosis will. And before anyone prescribes an antidepressant to a very young person, both a neuroimaging study and genetic testing may be required to assess the child's risk profile for dangerous, adverse events and unwanted side effects that the drug might cause.
It is not just medicine that will be responding to the explosion of diagnostic power that will flow from advances in genomics and neuroimaging. The ability to detect an abnormal brain may begin to shift thinking in the courts and criminal-justice system away from a punishment perspective toward a more therapeutic or medical model. If you are facing the death sentence in a highly controversial case, how quickly can your lawyer introduce a picture of your brain that shows gross abnormalities inconsistent with personal responsibility? Similarly, mental-health workers may find themselves called upon more and more often to offer their prognoses about who is likely to steal, embezzle, or harass at work. Before long, neuroimaging exams may supplant many of the familiar psychological and aptitude tests used in schools and the workplace today. And how long will it be before exclusive private nursery schools and kindergartens add a request for a brain-scan analysis to their admissions requirements?
The range and complexity of ethical issues raised by neuroimaging are as impressive as any that have accompanied any recent technological development in health care. Who will be paying for all this testing? When will such testing be mandatory -- upon entry to the military or the clergy, upon arrest, when seeking a marriage license? Who will do the testing, who will be able to see the results, and what standards will they answer to?
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The technology rolling toward us will even change how we think about mental health and mental illness. Today, drug abusers stick themselves with needles, risking diseases and addiction to get high. Tomorrow, you may be able to feed a signal right into the pleasure centers of your brain, giving you a much greater high without all the mess and risk. Is that a good thing? What if someone chooses to stay in a virtual world, remain attached to a pleasure-stimulating machine, or try to use new drugs or devices to boost their performance, mood, or sex drive or even modify a personality trait they don't like? Is "cosmetic" mental health a field of which our children will partake? Will debates about what to do about mental illness expand far beyond those we currently recognize as mentally ill?
There is also, of course, a profoundly positive side to this story. Improvements in diagnostics will guarantee improvements in treatments for millions of people suffering brain-related disorders. Already, better neuroimaging permits doctors to implant devices aimed at treating Parkinsonism or epilepsy deep into the brain. More precision forms of psychosurgery and a wider range of implantable gizmos are very likely to follow.
Similarly, advances in our ability to "pinpoint" drugs to an individual patient's genetic or neural makeup will bring enormous benefits. Today, we must often rely on "one size fits all" drugs that can be associated with serious risks and side effects. Tomorrow, when treatments become more and more efficacious with fewer and fewer problems, issues of access to care and the moral imperative to pay for it will come center stage in health-policy debates.
What can be used to treat can also be used to enhance. So the nascent trend in high schools and colleges among students and faculty to try drugs that help focus attention, or to permit a person to stay awake and function with less sleep, is likely to evolve into an enormous societal debate about the use of drugs or implants to boost productivity. Our grandchildren may well find that certain career paths are not open to them unless they are willing to undergo psychosurgery or take powerful cognition-enhancing drugs.
If the technology is built, then the field of mental health will bear little resemblance to the struggling, underfunded, often stigmatized, and somewhat mundane set of activities grouped under the mental-health banner that we are familiar with today. Mental health is about to fulfill the old Freudian dream -- resting psychiatry and psychology on a neuroscientific and biological foundation. That may not guarantee the delivery of the best mental-health care to those in need, but it will guarantee a revolution in the attitudes, expectations, and utilization of mental-health care services and knowledge. What once was a field fighting for parity and battling stigma is on the cusp of becoming a field where you would have to be crazy not to at least consider using what mental health will have to offer.
