Thomas Insel: Toward a new understanding of mental illness

Translator: Joseph Geni Reviewer: Thu-Huong Ha

Prevodilac: Maja Budišin Lukin Lektor: Mile Živković

So let's start with some good news,

Započnimo nekim dobrim vestima,

and the good news has to do with what do we know

a dobre vesti se odnose na to - šta mi znamo

based on biomedical research

o biomedicinskim istraživanjima

that actually has changed the outcomes

koja su zapravo promenila rezultate

for many very serious diseases?

mnogih veoma ozbiljnih bolesti?

Let's start with leukemia,

Započnimo s leukemijom,

acute lymphoblastic leukemia, ALL,

akutnom limfoblastnom leukemijom, ALL,

the most common cancer of children.

najčešćim oblikom raka kod dece.

When I was a student,

Kada sam bio student

the mortality rate was about 95 percent.

stopa smrtnosti je bila 95 procenata.

Today, some 25, 30 years later, we're talking about

Danas, nekih 25-30 godina kasnije, govorimo o

a mortality rate that's reduced by 85 percent.

smrtnosti smanjenoj za 85 procenata.

Six thousand children each year

Svake godine se izleči šest hiljada dece,

who would have previously died of this disease are cured.

koja bi ranije umrla od ove bolesti.

If you want the really big numbers,

Ako želite zaista visoke brojke,

look at these numbers for heart disease.

pogledajte ove brojke za bolesti srca.

Heart disease used to be the biggest killer,

Srčane bolesti su nekada bile najveći uzročnik smrti

particularly for men in their 40s.

pogotovo za muškarce u 40-im godinama starosti.

Today, we've seen a 63-percent reduction in mortality

Danas smo svedoci 63-procentnom smanjenju smrtnosti

from heart disease --

od srčanih bolesti -

remarkably, 1.1 million deaths averted every year.

izvanredno, više od milion smrtnih slučajeva se izbegne svake godine.

AIDS, incredibly, has just been named,

Neverovatno, SIDA je upravo prošlog meseca proglašena

in the past month, a chronic disease,

hroničnom bolešću,

meaning that a 20-year-old who becomes infected with HIV

što znači da se za dvadesetogodišnjaka zaraženog HIV-om

is expected not to live weeks, months, or a couple of years,

očekivalo da neće živeti nedeljama, mesecima, godinama

as we said only a decade ago,

kako smo govorili pre samo 10 godina,

but is thought to live decades,

već da će živeti decenijama

probably to die in his '60s or '70s from other causes altogether.

i da će verovatno umreti u starosti od 60 ili 70 godina od nečeg drugog.

These are just remarkable, remarkable changes

To su zaista izuzetno značajne, izvanredne promene

in the outlook for some of the biggest killers.

u prognozi kod nekih od najvećih uzročnika smrti.

And one in particular

Posebno kod moždane kapi,

that you probably wouldn't know about, stroke,

za koju možda ne znate

which has been, along with heart disease,

da je bila jednako kao i srčane bolesti

one of the biggest killers in this country,

jedan od najvećih uzročnika smrti u ovoj zemlji.

is a disease in which now we know

To je bolest o kojoj sada znamo

that if you can get people into the emergency room

da ako nastradalog možete da odvedete do hitne pomoći

within three hours of the onset,

u roku od 3 sata od nastanka,

some 30 percent of them will be able to leave the hospital

bolnicu će napustiti njih oko 30 procenata

without any disability whatsoever.

bez bilo kakvog invaliditeta.

Remarkable stories,

To su izvanredne priče,

good-news stories,

dobre novosti,

all of which boil down to understanding

koje dovode do razumevanja

something about the diseases that has allowed us

nečega o bolestima što nam je omogućilo

to detect early and intervene early.

da rano otkrivamo i da rano intervenišemo.

Early detection, early intervention,

Rano otkrivanje, rana intervencija,

that's the story for these successes.

to je priča o tim uspesima.

Unfortunately, the news is not all good.

Nažalost, ta vest nije u svemu dobra.

Let's talk about one other story

Pređimo na jednu drugu priču

which has to do with suicide.

u vezi sa samoubistvima.

Now this is, of course, not a disease, per se.

To, naravno, nije bolest sama po sebi.

It's a condition, or it's a situation

To je stanje ili situacija

that leads to mortality.

koja dovodi do smrti.

What you may not realize is just how prevalent it is.

Ne znate možda koliko je raširena.

There are 38,000 suicides each year in the United States.

U SAD je svake godine 38.000 samoubistava.

That means one about every 15 minutes.

To znači jedno u približno svakih 15 minuta.

Third most common cause of death amongst people

Treći najčešći uzrok smrti

between the ages of 15 and 25.

u starosti između 15 i 25 godina.

It's kind of an extraordinary story when you realize

To je neobična priča kada shvatite

that this is twice as common as homicide

da je dvaput češća od ubistava

and actually more common as a source of death

i u stvari, češći uzrok smrti

than traffic fatalities in this country.

od saobraćajnih udesa, u ovoj zemlji.

Now, when we talk about suicide,

Kada govorimo o samoubistvima,

there is also a medical contribution here,

ovde postoji i doprinos medicine,

because 90 percent of suicides

pošto je 90 procenata samoubistava

are related to a mental illness:

vezano za mentalne bolesti:

depression, bipolar disorder, schizophrenia,

depresiju, bipolarni poremećaj, šizofreniju, anoreksiju, graničnu ličnost.

anorexia, borderline personality. There's a long list

Postoji dugačak spisak

of disorders that contribute,

poremećaja koji tome doprinose

and as I mentioned before, often early in life.

i kao što sam ranije spomenuo česta su u ranom životu.

But it's not just the mortality from these disorders.

Ali kod tih poremećaja se ne radi samo o smrtnosti.

It's also morbidity.

Radi se i o morbiditetu.

If you look at disability,

Ako pogledate na invalidnost,

as measured by the World Health Organization

koju meri Svetska zdravstvena organizacija,

with something they call the Disability Adjusted Life Years,

s nečim što nazivaju DALY (Godine života podešene prema invalidnosti),

it's kind of a metric that nobody would think of

to je vrsta mere o kojoj niko ne bi ni pomislio

except an economist,

osim ekonomista,

except it's one way of trying to capture what is lost

osim toga to je jedan način kojim se pokušava uloviti izgubljeno

in terms of disability from medical causes,

zbog invalidnosti iz zdravstvenih razloga,

and as you can see, virtually 30 percent

i kao što možete videti, skoro 30 procenata

of all disability from all medical causes

od svih zdravstvenih invalidnosti

can be attributed to mental disorders,

može se pripisati mentalnim poremećajima,

neuropsychiatric syndromes.

neuropsihijatrijskim sindromima.

You're probably thinking that doesn't make any sense.

Verovatno mislite da to nema nikakvog smisla.

I mean, cancer seems far more serious.

Mislim, rak deluje mnogo ozbiljnije.

Heart disease seems far more serious.

Bolesti srca deluju mnogo ozbiljnije.

But you can see actually they are further down this list,

Ali one su zapravo niže na listi, kao što vidite,

and that's because we're talking here about disability.

i to je zbog toga što ovde govorimo o invalidnosti.

What drives the disability for these disorders

Šta je pokretač invalidnosti kod tih poremećaja

like schizophrenia and bipolar and depression?

kao što su šizofrenija, bipolarni poremećaj i depresija?

Why are they number one here?

Zašto su one ovde na prvom mestu?

Well, there are probably three reasons.

Verovatno postoje tri razloga.

One is that they're highly prevalent.

Jedan je da su veoma raširene.

About one in five people will suffer from one of these disorders

Otprilike jedan od pet ljudi oboleće od jedne vrste tih poremećaja

in the course of their lifetime.

u toku svog života.

A second, of course, is that, for some people,

Drugo je, da neke ljude

these become truly disabling,

to, naravno, zaista ohromi,

and it's about four to five percent, perhaps one in 20.

što se dešava u 4-5 procenata, možda jednom u 20.

But what really drives these numbers, this high morbidity,

Ali ono što zaista utiče na te brojke, na taj visok morbiditet

and to some extent the high mortality,

i do neke mere visoku smrtnost

is the fact that these start very early in life.

to je činjenica da one nastaju vrlo rano u životu.

Fifty percent will have onset by age 14,

Kod polovine će se pojaviti do 14. godine,

75 percent by age 24,

kod 75 procenata do 24. godine,

a picture that is very different than what one would see

što daje sasvim drugačiju sliku od one koja se vidi

if you're talking about cancer or heart disease,

ako je reč o raku ili o bolestima srca,

diabetes, hypertension -- most of the major illnesses

dijabetesu, hipertenziji - od većine glavnih bolesti

that we think about as being sources of morbidity and mortality.

za koje mislimo da su izvori morbiditeta i smrtnosti.

These are, indeed, the chronic disorders of young people.

To su u stvari hronični poremećaji mladih ljudi.

Now, I started by telling you that there were some good-news stories.

Obratio sam vam se sa rečima da imam neke dobre vesti.

This is obviously not one of them.

Ovo očito nije jedna od njih.

This is the part of it that is perhaps most difficult,

Ovaj deo je možda najteži

and in a sense this is a kind of confession for me.

i na neki način je jedna vrsta ispovesti za mene.

My job is to actually make sure that we make progress

Moj posao se sastoji iz toga da zapravo osiguramo napredak

on all of these disorders.

kod svih tih poremećaja.

I work for the federal government.

Ja radim za saveznu vladu.

Actually, I work for you. You pay my salary.

Zapravo radim za vas, vi mi dajete platu.

And maybe at this point, when you know what I do,

I možda ćete sada, kada znate šta radim

or maybe what I've failed to do,

ili možda šta sam propustio da uradim,

you'll think that I probably ought to be fired,

pomisliti da bi trebalo da me otpuste

and I could certainly understand that.

i ja bih to sigurno mogao da razumem.

But what I want to suggest, and the reason I'm here

Ali ono što želim da sugerišem i razlog zbog čega sam ovde,

is to tell you that I think we're about to be

to je da vam kažem da mislim da smo skoro zašli

in a very different world as we think about these illnesses.

u sasvim drugačiji svet ako razmišljamo o tim bolestima.

What I've been talking to you about so far is mental disorders,

Ono o čemu sam vam do sada govorio su mentalni poremećaji,

diseases of the mind.

bolesti uma.

That's actually becoming a rather unpopular term these days,

To, zapravo postaje prilično nepopularan izraz ovih dana

and people feel that, for whatever reason,

i ljudi osećaju, iz bilo kog razloga,

it's politically better to use the term behavioral disorders

da je politički bolje da se koristi izraz poremećaji ponašanja

and to talk about these as disorders of behavior.

i da se o tome govori kao o poremećajima u ponašanju.

Fair enough. They are disorders of behavior,

Pošteno. To jesu poremećaji ponašanja

and they are disorders of the mind.

i jesu poremećaji uma.

But what I want to suggest to you

Ali ono što bih voleo da predložim

is that both of those terms,

to je da su oba ova pojma,

which have been in play for a century or more,

koja su u igri sto godina ili više,

are actually now impediments to progress,

sada u stvari prepreke za ostvarivanje napretka,

that what we need conceptually to make progress here

a napredak koji treba ovde idejno da napravimo

is to rethink these disorders as brain disorders.

je da ponovno premislimo o tim poremećajima kao o moždanim poremećajima.

Now, for some of you, you're going to say,

Neki od vas će sada reći:

"Oh my goodness, here we go again.

"O bože, evo nas opet.

We're going to hear about a biochemical imbalance

sada ćemo slušati o biohemijskoj neravnoteži

or we're going to hear about drugs

ili ćemo slušati o lekovima

or we're going to hear about some very simplistic notion

ili ćemo čuti vrlo uprošćenu misao

that will take our subjective experience

koja će naše subjektivno iskustvo

and turn it into molecules, or maybe into some sort of

pretvoriti u molekule ili možda u neke vrste

very flat, unidimensional understanding

veoma jednostranog razumevanja

of what it is to have depression or schizophrenia.

o tome šta to znači imati depresiju ili šizofreniju."

When we talk about the brain, it is anything but

Kada govorimo o mozgu, to može biti sve drugo

unidimensional or simplistic or reductionistic.

samo ne može biti jednostrano, ni uprošćeno, ni redukovano.

It depends, of course, on what scale

Zavisi, naravno, na kom nivou

or what scope you want to think about,

ili u kom obimu želite da razmišljate,

but this is an organ of surreal complexity,

ali to je organ nadrealističke složenosti

and we are just beginning to understand

i mi smo tek na početku razumevanja

how to even study it, whether you're thinking about

čak i toga kako da ga proučavamo, da li kao

the 100 billion neurons that are in the cortex

100 milijardi neurona smeštenih u korteksu

or the 100 trillion synapses

ili 100 biliona sinapsi

that make up all the connections.

koje čine sve spojeve.

We have just begun to try to figure out

Tek smo započeli da odgonetamo

how do we take this very complex machine

kako da se latimo ove veoma složene mašine

that does extraordinary kinds of information processing

koja obrađuje informacije na izvanredne načine

and use our own minds to understand

i koristi naše sopstvene umove da razume

this very complex brain that supports our own minds.

taj zapleteni mozak koji je potpora našim sopstvenim mislima.

It's actually a kind of cruel trick of evolution

To je zapravo vrsta okrutnog evolucijskog trika

that we simply don't have a brain

da jednostavno nemamo mozak

that seems to be wired well enough to understand itself.

koji bi bio dovoljno dobro spojen da bi se sam razumeo.

In a sense, it actually makes you feel that

Na neki način vas on zapravo nagoni,

when you're in the safe zone of studying behavior or cognition,

da, kada ste na sigurnom području proučavanja ponašanja ili saznanja,

something you can observe,

nečega što možete da promatrate,

that in a way feels more simplistic and reductionistic

da se to na neki način čini jednostavnijim i redukovanijim,

than trying to engage this very complex, mysterious organ

nego pokušavanje da se bavite ovim veoma složenim, tajanstvenim organom

that we're beginning to try to understand.

koji počinjemo da pokušavamo da razumemo.

Now, already in the case of the brain disorders

Dakle, u slučaju moždanih poremećaja

that I've been talking to you about,

o kojima sam vam već pričao,

depression, obsessive compulsive disorder,

depresiji, opsesivno kompulsivnom poremećaju,

post-traumatic stress disorder,

posttraumatskom stresnom poremećaju,

while we don't have an in-depth understanding

iako nemamo produbljeno, suštinsko razumevanje

of how they are abnormally processed

kako se oni nenormalno obrađuju

or what the brain is doing in these illnesses,

ili šta mozak radi kod tih bolesti,

we have been able to already identify

uspeli smo već da identifikujemo

some of the connectional differences, or some of the ways

neke razlike u spojevima ili neke načine

in which the circuitry is different

na koje su tokovi različiti

for people who have these disorders.

kod ljudi s tim poremećajima.

We call this the human connectome,

Mi to nazivamo ljudski konektom

and you can think about the connectome

i možete ga zamisliti

sort of as the wiring diagram of the brain.

kao neku vrstu šeme za povezivanje mozga.

You'll hear more about this in a few minutes.

Čućete više o tome za nekoliko minuta.

The important piece here is that as you begin to look

Ovde je važan deo da kada počnete da posmatrate

at people who have these disorders, the one in five of us

ljude s ovim poremećajima, jednog od nas petoro

who struggle in some way,

koji se na neki način bori,

you find that there's a lot of variation

otkrivate da postoje mnoge varijacije

in the way that the brain is wired,

u načinu na koji je mozak povezan,

but there are some predictable patterns, and those patterns

ali da postoje i predvidljivi uzorci i oni

are risk factors for developing one of these disorders.

faktori rizika za razvoj jednog od ovih poremećaja.

It's a little different than the way we think about brain disorders

To je malo drugačije od načina mišljenja o poremećajima mozga

like Huntington's or Parkinson's or Alzheimer's disease

kao što su Hantingtonova ili Parkinsonova ili Alchajmerova bolest

where you have a bombed-out part of your cortex.

gde imate porušeni deo vaše moždane kore.

Here we're talking about traffic jams, or sometimes detours,

Ovde je reč o zastoju u saobraćaju ili ponekad o zaobilaznicama

or sometimes problems with just the way that things are connected

ili je ponekad problem samo u načinu kako su stvari povezane

and the way that the brain functions.

i načinu na koji mozak funkcioniše.

You could, if you want, compare this to,

Mogli biste to uporediti, ako želite,

on the one hand, a myocardial infarction, a heart attack,

s infarktom miokarda, srčanim udarom, na jednoj strani,

where you have dead tissue in the heart,

gde imate odumrlo tkivo u srcu,

versus an arrhythmia, where the organ simply isn't functioning

naspram aritmije, gde organ jednostavno ne funkcioniše

because of the communication problems within it.

zbog unutrašnjih komunikacijskih problema.

Either one would kill you; in only one of them

U oba slučaja biste mogli umreti; a samo u jednom od njih

will you find a major lesion.

naći ćete veliko oštećenje.

As we think about this, probably it's better to actually go

Kada razmišljamo o tome, možda je bolje da se, u stvari,

a little deeper into one particular disorder, and that would be schizophrenia,

malo udubimo u jedan određeni poremećaj, u šizofreniju,

because I think that's a good case

jer mislim da je to dobar primer koji doprinosi razumevanju

for helping to understand why thinking of this as a brain disorder matters.

zašto je bitno da se razmišlja o tome kao o moždanom poremećaju.

These are scans from Judy Rapoport and her colleagues

Ovo su snimci skenera Džudi Rapoport i njenih kolega

at the National Institute of Mental Health

na Nacionalnom institutu za mentalno zdravlje

in which they studied children with very early onset schizophrenia,

na kojima su proučavali decu s veoma ranom pojavom šizofrenije,

and you can see already in the top

i već možete videti u gornjem delu

there's areas that are red or orange, yellow,

područja koja su crvena ili narandžasta, žuta,

are places where there's less gray matter,

to su mesta u kojima je manje sivih ćelija,

and as they followed them over five years,

i kako su ih pratili u periodu od 5 godina,

comparing them to age match controls,

upoređivali ih s odgovarajućim kontrolnim starosnim uzorcima,

you can see that, particularly in areas like

the dorsolateral prefrontal cortex

možete videti da posebno u predelima

kao što je dorzolateralni prefrontalni deo korteksa

or the superior temporal gyrus, there's a profound loss of gray matter.

ili superiorni temporalni girus postoji temeljan gubitak sivih ćelija.

And it's important, if you try to model this,

I to je važno, ako pokušate da ovo modelirate,

you can think about normal development

as a loss of cortical mass, loss of cortical gray matter,

možete da razmišljate o normalnom razvoju

kao o procesu u kome se gubi masa moždane kore, sive ćelije korteksa,

and what's happening in schizophrenia is that you overshoot that mark,

i šta se dešava kod šizofrenije je to da preskačete normalne granice

and at some point, when you overshoot,

i u nekoj tački, kada preskočite

you cross a threshold, and it's that threshold

prelazite prag, a prag je taj

where we say, this is a person who has this disease,

gde kažemo, ovo je osoba koja ima tu bolest,

because they have the behavioral symptoms

zato što oni imaju simptome u ponašanju,

of hallucinations and delusions.

halucinacije i privide.

That's something we can observe.

To je nešto što možemo promatrati.

But look at this closely and you can see that actually they've crossed a different threshold.

Ako pogledate izbliza i možete videti da su zapravo prešli različite pragove.

They've crossed a brain threshold much earlier,

Oni su prešli moždani prag mnogo ranije

that perhaps not at age 22 or 20,

možda ne u starosti od 22 ili 20 godina

but even by age 15 or 16 you can begin to see

nego već u starosti od 15 ili 16 počinjete da uočavate

the trajectory for development is quite different

da je razvojna putanja sasvim različita

at the level of the brain, not at the level of behavior.

na nivou mozga, ali ne i na nivou ponašanja.

Why does this matter? Well first because,

Zbog čega je to važno?

Prvo zbog toga što, kod moždanih poremećaja,

for brain disorders, behavior is the last thing to change.

ponašanje je poslednja stvar koja se promeni.

We know that for Alzheimer's, for Parkinson's, for Huntington's.

Mi to znamo za Alchajmerovu, Parkinsonovu, Hantingtonovu bolest.

There are changes in the brain a decade or more

Promene u mozgu postoje deceniju ili više

before you see the first signs of a behavioral change.

pre nego što se primete prvi znaci promena u ponašanju.

The tools that we have now allow us to detect

Instrumenti koje sada imamo dozvoljavaju nam da otkrijemo

these brain changes much earlier, long before the symptoms emerge.

ove moždane promene mnogo ranije, mnogo pre nego što se simptomi pojave.

But most important, go back to where we started.

Ali, za ono što je najvažnije, vratimo se na početak.

The good-news stories in medicine

Dobre vesti iz medicine

are early detection, early intervention.

su rana otkrića, rane intervencije.

If we waited until the heart attack,

Da smo čekali do srčanog udara,

we would be sacrificing 1.1 million lives

svake godine bi u ovoj zemlji stradalo

every year in this country to heart disease.

više od milion života od bolesti srca.

That is precisely what we do today

To je tačno to što radimo danas

when we decide that everybody with one of these brain disorders,

kada se odlučujemo da svaki oboleli od jednog od tih moždanih poremećaja,

brain circuit disorders, has a behavioral disorder.

poremećaja moždanog toka, ima poremećaj ponašanja.

We wait until the behavior becomes manifest.

Mi čekamo dok se ponašanje ne ispolji.

That's not early detection. That's not early intervention.

To nije rano otkrivanje. To nije rana intervencija.

Now to be clear, we're not quite ready to do this.

Sada da razjasnim, mi još nismo sasvim spremni da to radimo.

We don't have all the facts. We don't actually even know

Nemamo sve činjenice.

Zapravo još ne znamo ni kakvi će biti instrumenti,

what the tools will be,

nor what to precisely look for in every case to be able

niti tačno šta da tražimo u svakom primeru da bismo mogli

to get there before the behavior emerges as different.

dopreti tamo pre nego što se pojave promene u ponašanju.

But this tells us how we need to think about it,

Ali ovo nam govori koliko je nužno da o tome razmišljamo

and where we need to go.

i gde treba da idemo.

Are we going to be there soon?

Da li ćemo uskoro u tome biti?

I think that this is something that will happen

Mislim da je to nešto što će se dogoditi

over the course of the next few years, but I'd like to finish

za sledećih par godina, ali bih voleo da završim

with a quote about trying to predict how this will happen

citatom o pokušaju predviđanja kako će se to dogoditi,

by somebody who's thought a lot about changes

nekoga ko je mnogo razmišljao

in concepts and changes in technology.

o idejnim i tehnološkim promenama:

"We always overestimate the change that will occur

"Mi uvek precenjujemo promene koje će se dogoditi

in the next two years and underestimate

u sledeće dve godine i potcenjujemo

the change that will occur in the next 10." -- Bill Gates.

promene koje će se dogoditi u sledećih 10." - Bil Gejts

Thanks very much.

Mnogo vam hvala.

(Applause)

(Aplauz)