cancer that can be prevented, yet we don't put our dollars there. going back to your expenditure discussion, why not? how do we change that? >> there are a couple reasons. one is what he said, we have had trouble coming up with these vaccines, if you will. the polio vaccine is probably the last big win we have had, that was 60 years ago. these are hard to come up with, that is part of the reason. part of the reason is the health care system has been paying for treatment of problems after they occur, not for prevention. on the hill, they are discussing health care reform, there is a lot of discussion about how to get people to engage in more prevention, with doctors and patients and everybody in the system. that is going to happen.

i am relatively optimistic that the payment system in health care is going to change to emphasize prevention and maintenance of chronic diseases where there is big dollars to be saved. >> bouncing over to what congressman gephardt was saying, ssris is the term that most people know because of advertises on television, they want to look like that blob on tv. in the 1990s, what other great advancements have we made with regard to treatment of mental illness? >> one of the most important things that we have learned, the most effective treatments actually combine medication with behavioral treatment. that is very difficult to sell because they don't understand. there is a large body of data

that says antidepressants work and if you are chronically depressed, you should take antidepressants for a long period of time. if you add certain clinically tested, clinical trial tests, you can advance, you can increase the success rate. that combination is more successful than having a general practitioner who doles out an anti-depressant. >> where we have led the community is we have not been able to translate the increases, the nature of these disorders and to better treatments. they worked on serotonin and are very good for particular people. we don't know much about matching.

congressman gephardt made the comment, some respond to lipitor, how do you find it? you try it. we at doing that with mental disorder treatments. we need to find a way to move forward in translating what we are learning about basic science. a reasonable question is, is the basic science ready? i don't know the answer to that question. >> a couple things are important we different about the lipitor example and medical example. when you do the trial to look at these studies, whether there are genes that predict, it takes 10 years to know what you are talking about, can i prevent a heart attack. there is the potential for getting someplace lot quicker. the treatment for mental

disorders. is so expensive as you mentioned, the money is not there for treatment for mental disorders, most of the new medications are variations on the theme. we don't have the range of mechanism of actions that you find further disorder is. we don't see much because we don't have the range. various ellises, you look at how much money is spent on treatment. the biggest mismatch, that has the highest burden and los treatment is mental disorders. nothing comes close. >> why is that? >> i have often wondered why there's so much money for cardiovascular disease and someone pointed out that a lot of people in congress are

middle-aged men. a lot of things about who is making these decisions. >> we struggle for years, parity and health care insurance for mental disorders. >> one thing is a different place, we talked about leveraging government action. when you look at the workplace, as you know from being on boards, there's an enormous amount of money invested in health care in the workplace. increasingly employers are seen not as a cross of doing business but as human capital investment. we are discovering, when you start looking at the workplace cost of illnesses, over and over again, when you look at the most costly conditions, 3 come up, seasonal allergies, low back

pain and mental disorders. the place that you can make the biggest impact is to -- the door of the factory, going after mental disorders, depression, bipolar disorder, substance problems. these are of of things that have the biggest impact on human capital production. the research, and intervention studies are showing employers that this is a smart business moved to find people with mental disorders. when you look at health campaigns, depression is the biggest health campaign in corporate america. they are following the money. we are having a tough time making that sell in the government because there's not a customer or a bottom line. when you make a rational case and put it in front of people

and lawyers are leading the way. >> health-insurance pays for these anti-depressant drugs. >> some of that has to do with what we know so far and what the molecular targets are to develop better treatments. we don't have such spectacular ones. there's one other issue we don't talk about a lot. that is the obsession with large diagnostic categories. in mental illness we have a tendency to want to treat schizophrenia. what is schizophrenia? it is a combination of symptoms. if we moved our strategy to treating symptom clusters, we talk to the patients.

for a pharmaceutical company trying to sell something, the large trials, very big affect, it is very difficult because it is hard to say everybody who is depressed needs the same treatment, everyone who has bipolar disorder needs the same treatment, schizophrenia is the most complex example of it. pharmaceutical companies develop treatments, what is it you are treating? it is much harder than if you are trying to treat the specifics like getting your blood pressure down. that is different. >> congressman gephardt, i have a great deal of respect for you,

followed your career. thousands of issues must have come across your desk. why this issue? what does it mean to you? >> i have always said health care is more important to my constituents than any other issue. i used to tell crowd you could be bill gates and have $50 billion but if you get sick with a horrible disease, the money doesn't mean anything. it has no importance. you have a personal story, i have a son who in 1972 was diagnosed with terminal cancer. it was in his prostate, a rare diagnosis. it invaded is the domino cavity, they gave him no chance that they found a triple drug therapy they thought might work.

they combined that with radiation, he is 38-year-old, living in atlanta, georgia. [applause] >> nothing you can tell me about this, we went through 5 years of intense therapy. the doctors said you may not want to do this because the collateral stuff will be so ugly that he won't want to be alive. we went on, didn't take that advice, his grandson, you had him on a tv show, learning to swim at age 1. it is all in the family here. it is all personal stories. that is why i always cared about

this issue so much and still care. i will care about it until the day i die because it is so important to everybody. there are few things you can deal with, huge economic consequences. people could be healthier, they will be more productive workers, we would have a better economy, we save money in the health-care system, we could provide health care for everybody. with what we are spending, 16% of gnp, everybody ought to have health insurance. if we would stop wasting so much money. finally, the emotional, personal thing, when somebody in your family or you, you want answers and you want them now. >> you are saying between 2 giants in mental health today, you are listening to them talk. can you give us -- based on what you are hearing today, you're spending time with the

president, trying to put mental health on the agenda as part of health reform. what are the things you would tell leaders who are making these decisions? >> i think there has been a huge shift in understanding among policymakers about the interrelated this of mental health. the president gets it completely. that is a big step in the right direction. i think it continues to be important for people in the audience to keep educating policymakers, get in front of people, give them the information that these 2 learned people are giving today to the policiesmakers directly. they have to deal with so much subject matter, they are distracted, they have 1 million things in front of them, try to get them to focus on the

importance of this health-care debate. finally, it is really vital to make policy is about makers understand that we can move the needle if we just do it a few of these things we are talking about. it is not very complicated. you have got to have more money, you have got to invest. we need revolution of the fda. we need the fda to be more than it has been. it has to become involved in finding answers to diseases. it is not just to make things safer. is to helped develop things that will solve problems. they have got to be brought into the process. this translation research thing has got to be done. we have got to explain that to people. finally, we have to get health care reform. in 1993 we fail.

we were pigheaded, including myself. we said it has got to be this way or we're not going to do it. that was stupid. that was really stupid. i don't want them to do that this time. i want them to compromise, find common ground. when you go into the emergency room, you are not republican or democrat, you are just sick and you want to be well. that is what people want. this is a huge. we cannot miss this opportunity. this year it has to happen. if it goes into next year it won't happen because there will be an elections. we have to do it this year. [applause] >> he is not running any more. >> never again. >> i am up their many days talking to my friends about doing this. i think we are going to get it

done. i am optimistic. >> amazingly candid remarks about 93 and what happened and what didn't work. how optimistic are you? >> i don't know a great deal about the political process. i don't have -- i am a naturally optimistic person. as you were talking about the human capital investment, forward thinking people. over the last year i have been working in another country that has a very different model. in third world countries, there is a great deal of interest in human capital investment, doing this stuff to attract international capital. every kid in the entire country is screen for mental disorder in first or second grade and they have a national system for getting kids into treatment. they feel that in order to keep

the country final in the international economy they have to invest in the health and education of the next generation. they are thinking this forward way in which we are not, we are holding on to what we have. they are trying to figure out how to get from here to there. the hope is this forward thinking, that this administration has, which is so evident, many things will push us over -- >> can i ask a quick question? screening programs for young children in peru, what are those and do they work? >> u.s. researchers are guiding much of the work. people who are developmental psychologists and child psychiatrists, the programs that have been developed have been developed at johns hopkins, a harvard, ucla, we are in the process, the fifth year of following these kids.

this is one of these ones like lipitor. we are not trying -- it is a real prevention. you don't say i have got an ellis, let me see if i can treat the episode and in 90 days i will tell you. we are halfway through. >> one of the questions you brought up earlier, if the child has a seemingly irrational fear of dogs, are these the questions that get asked? >> early on, alan can tell you, you don't see clear illnesses among kids very often. you wait a while and the illness declares itself. there is an impulsive sort of fearful, moody -- they are odd kids. you go after these spectrum's. one of the ones they use the first is fearful less. the other one is impulsive less.

you don't see depression until teenage years. the impulsive, aggressive, fearful kids. >> nature or nurture? >> 50% is nurtured. environmental effects interact with genetic. it is a combination of the wrong genes at the wrong time at the wrong place. in terms of variants, nature is more important than nurture. >> nurture is more important

than nature. environment is more important than jeans but both play a big part. >> they played a part together. the fall in a way we don't understand. >> that is one of the big questions we will have to face overtime. to say that all things are determined by interaction between genes and the environment is true. the question that is important is how does the environment affect gene expression? how does the gene makes you susceptible? in drug abuse, we are starting to see that certain genetic predispositions make people more susceptible, example, to the pleasant effects of stimulant drugs. everybody knows, some people like marijuana, some people don't like marijuana. it is not a stimulant. some people like it, some people don't like it, what is that? it is a genetic difference, but

once you have had it and once you have been using it for a while, the environmental factor comes to play. and interesting kind of thing to figure out, get beyond the truism can't get to the mechanism through which these things can, in fact, interact, if you take that step further, if someone did not have a clinically diagnosed mental illness, take depression for example, yet they begin an anti-depressant. what will happen to them? >> nothing. >> will they be cheerier of mood than normal? >> does not appear to be. if you have a very low level of depression and give someone an anti-depressant you will normalized them, but there's no evidence to suggest that the antidepressant has a stimulatory effect. it doesn't work that way. >> that is not true for all classes of drugs. if you don't have adhd and you

take an adhd medicine, you will concentrate better. there's a lot of concern about using these drugs to perform better, kids in colleges illicitly using drugs, they have a roommate who has a medication, the roommate will sell him the medication the week before the exams. it will help everybody. >> i know what you are going to answer but i am curious, what is wrong with that? [applause] >> talk about why heart disease gets funded so well. >> there is a complicated debate about this. ideas of fairness and morality. some of the arguments are silly,

it is not natural. some of the stimulant drug that exist right now have serious side effects. you wouldn't want people on their own to make the decision that they are willing to risk the downstream things, it puts limits, you can decide to drive at 35 miles an hour but you can't decide to drive at 120. people with a 7 level of need, society besides, there's a lot of interest particularly for elderly people, a.d. hd medications given to elderly people to push off the early effects of alzheimer's disease. >> cognitive enhancing medications, that is something we will be hearing a lot about, about the morality, legality and so forth. >> not to be labor the point but let's say you came up with a

good cognitive enhancement drugs that have a low side effect profile, give it to everybody. i am just making that up. >> there is no reason that it is unethical to do better. all of these substancess are dangerous if misused. that is where the problem comes. just a quick fact. if you give stimulant drug is to a child with a ph.d. it works. if they don't become addicted to it, it actually reduces their probability of later developing

an addiction. it is a balance the screen taking it because you need it or because you think it will make you perform better. these are complex issues which is why we have doctors. >> you said we are not where we should be. where do you see us going? what the you think the next 15 years are going to look like? >> i believe science is hope. if you look at the basis of the track record of science, in my field, neuroscience, we have learned more about the brain that in all of recorded history.

the advance is phenomenal. even in mental disorders, advances in neuroscience have revolutionized our understanding of mental and addictive disorders. we are going up and fast. >> this is something you are passionate about. where do you see us in a decade or so? >> i am not a scientist, i don't even know what i am talking about. [laughter] >> there are drugs for that. i need them now. when i listen to scientists they talk about personalized madison, the genome project, your personal gene map, biome markers. it seems to me we are on the

threshold of huge gains, huge change. i often tell the story, i am really old. when i was a kid in st. louis, kids were getting polio. i remember like yesterday, a girl i went to grade school with, i was 849-year-old. they brought her out of the house and the neighborhood gathered to watch this happen. they brought her out of the house in an iron lung and put her in an ambulance. we were all petrified that we would get polio. in fact, i had psychosomatic polio a few weeks after that. my legs got numb because i was so fearful that i was going to go out of the house in an iron long. that is how traumatic this was

to people. and i remember jonas salk on the television saying we have this vaccine that we could all get. it was like a weight had been lifted off of our shoulders. we are on low threshold -- how wonderful it would be. we need to put more money in basic science and translation of science, we need science to be cool. we need to get health care reform. if we do that we will have a great day. >> i am feeling better already. summary remarks, you are an optimistic guy. 10 years from now where do you think you are going to be? >> i am a social scientist. we were picked because we do different stuff. i am looking forward to the

success of the jenna mix revolution. we see the effect of the environment much more clearly when you can understand the genetics. >> hard to know what is environmental and what is genetic. when we see the genetic effects, we will be able to study the interaction that we will see what the environmental contribution is in a clear way. it turns out that that is 50% of what is going on. then we will get to the next step, between discovering the perfect way of doing things and getting it to be done perfectly. the iron lung example, for a number of years, as soon as people had a baby, they were ready to be on the list. the number of kids showing up at kindergarten who were not vaccinated has been going up because those young mothers never it lived in a world where they saw somebody with an iron

lung. getting people to take a vantage of what exists, taking the good treatments that we know how to do and make sure they are done the right way in practice, that is what i do. there will be developments in parallel with the genetic revolution. that will be the ultimate promise of getting from here to there. that is the other 90 yards. >> a big round of applause for the panelists. [applause]