Brave New Brain: Conquering Mental Illness in the Era of the Genome

Most psychiatrists now recognize that dysfunctions of mood regulation, perception, cognition, and behavior are medical illnesses that usually involve disorders of the brain and, frequently, other organs and somatic systems. When patients are first diagnosed as having psychiatric illnesses, they invariably have questions about all aspects of their disorders and the treatment recommendations. It is reasonable to expect that, as our field learns about the biological aspects of mental illness, our patients also will desire and expect more in-depth information about these components of their conditions. The following are samplings of questions that my patients have had about depression, the answers to which involved biologically related information:

My daughter experiences unbearable suffering from depression. What did I do wrong as a mother?

After not being depressed for the first 43 years of my life, why and how did I suddenly get sick at this time?

Are you saying that my changing hormones during menopause could make me vulnerable to depression? How exactly does that work?

Could the stress of losing my husband have changed my brain chemistry?

You say that my brain is involved in depression. What actually is going on in there?

Why do I have to wait so long for the antidepressants to “kick in?”

You said that antidepressants treat the underlying illness of depression, rather than just “covering over” my symptoms. Does this mean that the medications will cure my illness?

What are the chances that my children will “inherit” my depression?

For many years, in addition to doing my best to answer my patients’ questions about the biological aspects of their illnesses in the treatment setting, I have also recommended their reading The Broken Brain: The Biological Revolution in Psychiatry, by Nancy Andreasen (1). Invariably, my patients have been interested in and encouraged by what they have learned. Additionally, the information and understanding gained have complemented our therapeutic work and enhanced their recoveries. Dr. Andreasen began to conceptualize The Broken Brain almost 40 years ago—long before her distinguished accomplishments in neuroscience research, neuropsychiatry, and as editor of this preeminent journal of psychiatry. In fact, she had not yet become a physician. At the time, she was an English professor, pregnant with her first child and seriously curious and concerned about the biology of reproduction. In The Broken Brain, Dr. Andreasen wrote,

The Broken Brain was published in 1984. In that text, Dr. Andreasen established a new publishing standard for clarity and compassion in describing, in ways that are enlightening, useful, and comforting to patients and their families, the essentials of psychiatry’s revolutionary return to mainstream medicine. The first portion of the book traced the early history of psychiatry and the origins of the stigmatization of the mentally ill, reviewed the competing conceptual models for understanding and treating people with mental illness, and answered fundamental questions, such as, What is mental illness? What is the brain? How does one make a psychiatric diagnosis? How do the new medications and brain imaging tests work? and What causes mental illnesses? The result of this effort is what I and many, many other psychiatrists believe to be our field’s most authoritative, helpful, and influential text on mental illness for patients and their families.

Dr. Andreasen’s new book, Brave New Brain: Conquering Mental Illness in the Era of the Genome, is much more than a sequel to The Broken Brain. In her new book, the author sets her sights even higher. Her lofty goal is to review and explicate the remarkable explosion of knowledge related to the neurobiology of mental illness that has occurred over the 17 years since the publication of The Broken Brain. Additionally, the bold new book is a powerful argument for Dr. Andreasen’s controversial assertion that scientific advances, recent and imminent, will lead us to “discover a brave new world in which mental illnesses, now painfully common, become infrequent and easily treated” (p. xi). To accomplish these daunting goals, she calls on her formidable skills as a writer, teacher, clinician, and scientist scholar and relentlessly presents fascinating and relevant information—compelling evidence to corroborate her exciting thesis. Irresistibly, the reader of Brave New Brain becomes drawn in, involved, informed, and, ultimately, convinced.

Brave New Brain is divided into four parts. The initial section reviews the overwhelming personal and economic toll of mental illnesses. Dr. Andreasen wields an unyielding scalpel—case studies—to expose the painful disabilities wrought on patients and their families by psychiatric disorders. The case histories also reveal the frustrations resulting from stigma and the limitations placed on mental health practitioners by oversimplified conceptualizations of the “causes” and treatments of mental illnesses.

In part 2, the author becomes tutor and teacher as she explains what the new scientific information has revealed about what the brain is and how it works. She moves deftly from the macro-anatomy of the brain (“It weighs just over two pounds. We each get issued only one.”) (p. 41) to cellular and molecular biology (“All the physical growth or degeneration and all the physical and mental responses of that single human being are determined by DNA in the cell nucleus—as it interacts with external ‘events,’ from nearby changes in cell temperature to very distant ones such as the mental stress that occurs if a person is raped or mugged.”) (p. 105). In addition to the first chapter, “The Brain,” the two other long and remarkable chapters in this section—“Mapping the Genome: The Blueprint of Life…and Death” and “Mapping the Mind: Using Neuroimaging to Observe How the Brain Thinks”—present a current, comprehensive, and comprehensible review and reference, for both patient and practitioner, of the “new science” of psychiatry.

Section 3 provides an update of scientific advances in the four major categories of mental illnesses that Dr. Andreasen focused on in her first book: the schizophrenias, mood disorders, anxiety disorders, and dementias. Emphasis is placed on applying recent discoveries in genetics, molecular biology, cell biology, and brain imaging to enhance our understanding of these specific conditions. Dr. Andreasen offers a report card on the advances of science and medicine in the nosology, pathophysiology, treatment, and prevention of these disorders. As one would expect, she is a fair but hard grader (e.g., D+ for progress in the treatment of dementias). No reflexive flag-waver for our profession, the author takes on, for example, some of the limitations of DSM: “The scientific basis of DSM is credible. But it is not infallible. Because DSM has become institutionalized in training programs and quality assurance testing programs, it is revered too much and doubted too little.…Many research scientists are concerned that DSM criteria may limit creativity and flexibility in thinking, which may inhibit progress in understanding the underlying mechanisms of mental illness” (p. 182).

By part 4 of Brave New Brain, Dr. Andreasen has constructed the data-reinforced foundation from which to launch and defend her contention, “During the coming century we will combine our knowledge of the human genome and our knowledge of the brain to develop new weapons with which to wage a war on mental illness that may eventually lead to a definitive victory” (p. 317). In addition to articulating a convincing strategy about how such a war could be waged and won, the author also presents the challenging hurdles (e.g., ethical issues arising with each scientific advance) and pitfalls (e.g., psychiatrists’ “overreaching” by aspiring to be agents of social change) that would impede victory. The net result of the author’s argument is a vision for combating mental illness that is both hopeful and realistic.

I encourage all psychiatrists to read Brave New Brain. Almost magically, by centering on the recent and future scientific advances that are invigorating psychiatry, Dr. Andreasen has captured and expressed for us the immense purpose, potency, and potential of our profession. I will recommend this book to my patients and their families and to my students regularly and with unalloyed conviction. In a manner that is both lucid and involving, this book presents essential information about the understanding and optimal care for people with mental illnesses, while offering realistic and requisite hope.