Special reportMental illness

Young adults

Making cruel unusualThe treatment of severe mental illness used to be barbaric Sometimes it still is

Jul 11th 2015 | From the print edition

A COUPLE OF miles from Congress inWashington DC sits a large complex ofbuildings in a redbrick Italianate style withterracotta roof tiles It might be mistaken for acollege were it not for the ironwork in front ofthe windows to stop people from jumping outThis is the old St Elizabeths Hospital once oneof the largest asylums in America It nowstands empty awaiting redevelopment for the Department of Homeland Security

The hospitalrsquos walls contain a potted history of the way severe mental illness has been treatedover the past 200 years in particular schizophrenia (whose victims hallucinate and withdrawfrom society) bipolar disorder (which causes frequent mood swings from mania to despairand back again) and severe personality disorders (a catch-all term for people who behave invarious abnormal ways) Their incidence varies little from country to country affecting 15-3 of the population over the course of a life They most often emerge between the ages of 18and 25

In the West the asylum movement which began in the first half of the 19th century (and wasthe inspiration for giant hospitals like St Elizabeths) offered a combination of rest andrestraint and held out the promise of scientific cures for those afflicted But once inside fewpatients ever got out undermining the idea that there was any treatment going on Inpractice asylums mainly served to keep the mentally ill off societyrsquos back In the 1950s theworldrsquos largest the Georgia State Asylum in Milledgeville had up to 10000 patients at anyone time The hospitalrsquos grounds still contain the unmarked graves of 25000 who died there

The idea that this was not an acceptable way to treat the mentally ill first gained currency in

America Erving Goffman a sociologist spent a year working incognito in St Elizabeths andwrote about his experience in his book ldquoAsylumsrdquo published in 1961 He saw a flourishinginternal economy that ran on cigarettes and cash earned by washing the hospital staffrsquos carsand noted that the 7000 or so patients conducted romantic relationships with each other viaa clandestine network of note-passing There were also a lot of card games ldquoA readiness toaccept an individual as an acceptable participant in a game of poker or blackjackrdquo he wroteldquowas sometimes quite independent of his simultaneous manifestation of psychoticsymptomsrdquo Goffmanrsquos readers were left wondering whether the inmates of his asylum reallywere mad

The 1960s saw the rise of an anti-psychiatry movement which argued that madness wasinvented by society as a way of exercising power over people who refused to conform TheKennedy familyrsquos personal experience played an important part in the re-evaluation ofmental illness Rosemary Kennedy John F Kennedyrsquos sister had been left in a near-vegetative state after a lobotomy performed by Walter Freeman a doctor who travelledaround America severing the frontal lobes of more than 3000 people with a kitchen ice pickThe operation was supposed to calm down aggressive mental patients In 1963 John FKennedy signed the Community Mental Health Act which aimed to close the asylums andtreat mental disorders more like illnesses and less like crimes

Shutting asylums turned from being a leftish cause in the 1960s and 1970s to a rightish onein the 1980s The abuse of psychiatric institutions in the Soviet Union a country whichdeveloped a new diagnosis of ldquosluggish schizophreniardquo to redefine political dissidence as anillness made asylums in the West seem like local outposts of totalitarianism As governor ofCalifornia Ronald Reagan became an enthusiastic closer of asylums attracted by theresulting increase in freedom and decrease in government spending

The decline of asylums in the West ended a shameful chapter in the history of psychiatry butleft an important question unresolved how should society deal with seriously ill people whothemselves may prefer to be left to their own devices Psychiatric patients had often beensubjected to cruel and unusual treatment such as using them for medical research withouttheir consent or administering electric-shock treatment so forceful as to result in brokenbonesmdashnot to mention more casual unkindness Now most countries try to strike a betterbalance between what psychiatrists think is in the interests of their patient and the patientrsquosown wishes

America is in the middle of a fierce political argument over whether it currently has thebalance right At a meeting in May organised by supporters of a bill proposed bycongressman Tim Murphy Anthony Hernandez told the story of how his son last year triedto kill both him and his wife while they lay in bed one morning The son apparently wished tosacrifice his parents thereby sending them to heaven (though he succeeded only in stabbingthem and bludgeoning the family dog to death) Mr and Mrs Hernandez had previously been

unable to force treatment on their son while he was violent and delusional After the attack apolice officer arrested the son who is now in a county jail charged with double attemptedmurder and animal cruelty His tearful father says his son is being bullied by other inmatesand is not taking his medication Congressman Murphyrsquos bill aims to give families the powerto enforce treatment in such cases

This might seem a perfectly reasonable proposal but it has met with opposition from peoplewho still associate psychiatry with the outrage of the asylum One such person is Dan FisherMr Fisher who comes from a family of doctors was doing research into the biological basisof schizophrenia at the National Institute of Mental Health in Bethesda in the 1960s when hehimself was diagnosed with catatonia a condition that often renders its victims mute He washospitalised twice ending up at the Navy Hospital in Bethesda where he did not speak for amonth and was so incensed by the way he was treated there that he became determined toget as many patients as possible out of hospital He trained as a psychiatrist suffering a fewmore relapses in medical school and has since become a leader in the recovery movement aloose alliance of former patients that draws inspiration from the gay- and disabled-rightsmovements and has a scratchy relationship with the psychiatric profession

People who receive proper treatment as soon as their symptoms appear recover more quicklyand have a less fraught relationship with their doctors

What both sides can agree on is that a large number of people with severe mental illness arestill being treated scandalously badly sometimes no better than during the asylum era Partof the old St Elizabeths Hospital has been turned into a new much smaller one bearing thesame name Its best-known patient is John Hinckley who in 1981 shot at Ronald Reagan andhis press secretary Jim Brady who was paralysed by the assault Demand for the hospitalrsquosbeds outstrips availability which means that patients who may need to go into an institutionfor a while are held somewhere else That somewhere else is the DC jail A recent visitor fromthe federal government encountered seriously ill people arrested for minor offences such asurinating in public being held in solitary confinement for 23 hours a day dosed up onsedatives (The prison did not respond to several requests to let The Economist in)

The DC jail is not an isolated example across the country people with serious mentalillnesses are more likely to be in a prison than in a hospital On any given night Cook Countyjail in Chicago houses a couple of thousand people diagnosed as mentally ill a situation thatthe countryrsquos sheriff Tom Dart has described as ldquoan abominationrdquo Rikers Island prison inNew York has become notorious for its guards beating up inmates with mental disorders Butlife for mental patients can be violent outside too the National Sheriffsrsquo Associationestimates that more than 400 people shot and killed by the police in America every year arementally ill

Much of this could be avoided by identifying and treating serious mental illness earlierThere is no single gene that predicts someone will contract such an illness later in life thoughif one of a pair of identical twins has schizophrenia the other has a near 50 chance ofbecoming ill too On average people diagnosed with schizophrenia do not receive treatmentuntil three years after the first onset of their symptoms At that point they are typicallyhospitalised after a trip to the accident and emergency department where confused andhallucinating they are given a large dose of antipsychotic medicine Unsurprisingly thosewho first encounter hospitals this way are keen to avoid them thereafter

Researchers are now discovering more about what puts someone at risk of developingschizophrenia or bipolar disorder Some of it has to do with peoplersquos circumstances such aswhere and how they live Combined with cognitive tests and family medical histories suchinformation should make it possible to intervene earlier John Kane of Hofstra North Shore-LIJ School of Medicine in New York has shown that people who receive proper treatment assoon as their symptoms appear recover more quickly and have a less fraught relationshipwith their doctors And they can be treated with far lower doses of antipsychotic medicinethan traditionally prescribed That matters because some of these drugs have unpleasantside-effects including weight gain that discourage people from taking them

Cheer up

But newer sorts of drug treatment look promising too particularly for depression This is themost widespread of mental disorders yet it remains ldquonearly incomprehensible to those whohave not experienced it in its extreme moderdquo wrote William Styron who described his near-fatal encounter with depression in a memoir called ldquoDarkness Visiblerdquo Each afternoon afterfour orsquoclock Styronrsquos head ldquobegan to endure its familiar siege panic and dislocation and asense that my thought processes were being engulfed by a toxic and unnameable tide thatobliterated any enjoyable response to the living worldrdquo

Carlos Zarate at Americarsquos National Institute of Mental Health (NIMH) treats people withsevere depression and bipolar disorder with intravenous ketamine Though often takenrecreationally this is a fairly nasty drug Americarsquos Drug Enforcement Agency has givenwarning that it is being used as a sedative in date-rape cases Those who snort it over anextended period to get a high sometimes find it makes them incontinent Yet to the otherfederal agency that takes an interest in drugs the Food and Drug Administration it looksrather attractive The FDA has given ldquobreakthrough therapyrdquo designation to ketamine as theclosest thing to a miracle cure for cases of severe depression and bipolar disorder

Dr Zarate works with patients who have notresponded to six or seven other forms oftreatment sometimes includingelectroconvulsive therapy Half of the bipolarpatients on whom he has tried the treatmenthad previously attempted suicide Over thecourse of a 40-minute infusion patients losetrack of time hear sounds as if muffled by athick blanket see traces of bright lights and find their thoughts muddled Yet an hour latermore than half of them feel their depression has lifted ldquoThese are patients who a couple ofhours ago were saying lsquoI want to die Irsquom uselessrsquo who are asleep all dayrdquo says Dr ZarateThe effects of ketamine lasts about a week and tests repeating the experiment over a longerperiod are now in process Nobody is quite sure why it works but Dr Zarate hopes that bydoing lots of brain scanning and gene investigation he and other researchers will get a betteridea

Advances in medical technology should also help to keep mental patients out of hospitalDror Ben-Zeev at Dartmouth College has conducted several promising trials using mobilephones to keep an eye on such people In its most basic form this means using text messagesto ask them how they are feeling and remind them to take their medication In a moresophisticated version peoplersquos symptoms are monitored through their smartphones andappropriate care offered If someone is hearing voices telling them not to go outside orsomething terrible will happen says Dr Ben-Zeev a clinician on the other end of an app canask them to try it and see and then report back to him

Since most smartphone users check their devices when they first wake up in the morning andjust before they go to bed those phones can also serve as basic sleep monitors Bouts ofpsychosis are often foretold by irregular sleep patterns A phone can be used to garnerinformation about a patientrsquos physical activity too another useful predictor of distress

What someone does with their phone can alsobe telling Tanzeem Choudhury who works onthis technology at Cornellrsquos department ofcomputer science points out that people in themanic phase of bipolar disorder often go onspending sprees using their phones to shopand gamble If early identification andtreatment can be refined and offered morewidely people with serious mental illness may be able to look forward to a brighter future

Sitting around in a circle with a handful of Dr Kanersquos outpatients at the Zucker HillsideHospital in New York all of them in their 20s and diagnosed with some form ofschizophrenia it is possible to imagine what such a future might look like The hospitalrsquosrooms with their big windows and plywood furniture resemble bedrooms in aScandinavian-inspired business hotel One of the few signs that they are not are thewardrobes with their doors sloping so that nothing can hang from them

Michael who writes poetry and rap lyrics in his spare time has a complicated relationshipwith the voices he hears in his head Sometimes he is able to converse with Voltaire but if hegets no help they can become a deafening 24-hour-a-day cacophony Now he hears them onlya few times a day for a minute or so at a time With luck he should be able to live the rest ofhis life without fear of being locked up in places like St Elizabeths

From the print edition Special report

unable to force treatment on their son while he was violent and delusional After the attack apolice officer arrested the son who is now in a county jail charged with double attemptedmurder and animal cruelty His tearful father says his son is being bullied by other inmatesand is not taking his medication Congressman Murphyrsquos bill aims to give families the powerto enforce treatment in such cases

This might seem a perfectly reasonable proposal but it has met with opposition from peoplewho still associate psychiatry with the outrage of the asylum One such person is Dan FisherMr Fisher who comes from a family of doctors was doing research into the biological basisof schizophrenia at the National Institute of Mental Health in Bethesda in the 1960s when hehimself was diagnosed with catatonia a condition that often renders its victims mute He washospitalised twice ending up at the Navy Hospital in Bethesda where he did not speak for amonth and was so incensed by the way he was treated there that he became determined toget as many patients as possible out of hospital He trained as a psychiatrist suffering a fewmore relapses in medical school and has since become a leader in the recovery movement aloose alliance of former patients that draws inspiration from the gay- and disabled-rightsmovements and has a scratchy relationship with the psychiatric profession

People who receive proper treatment as soon as their symptoms appear recover more quicklyand have a less fraught relationship with their doctors

What both sides can agree on is that a large number of people with severe mental illness arestill being treated scandalously badly sometimes no better than during the asylum era Partof the old St Elizabeths Hospital has been turned into a new much smaller one bearing thesame name Its best-known patient is John Hinckley who in 1981 shot at Ronald Reagan andhis press secretary Jim Brady who was paralysed by the assault Demand for the hospitalrsquosbeds outstrips availability which means that patients who may need to go into an institutionfor a while are held somewhere else That somewhere else is the DC jail A recent visitor fromthe federal government encountered seriously ill people arrested for minor offences such asurinating in public being held in solitary confinement for 23 hours a day dosed up onsedatives (The prison did not respond to several requests to let The Economist in)

The DC jail is not an isolated example across the country people with serious mentalillnesses are more likely to be in a prison than in a hospital On any given night Cook Countyjail in Chicago houses a couple of thousand people diagnosed as mentally ill a situation thatthe countryrsquos sheriff Tom Dart has described as ldquoan abominationrdquo Rikers Island prison inNew York has become notorious for its guards beating up inmates with mental disorders Butlife for mental patients can be violent outside too the National Sheriffsrsquo Associationestimates that more than 400 people shot and killed by the police in America every year arementally ill

Much of this could be avoided by identifying and treating serious mental illness earlierThere is no single gene that predicts someone will contract such an illness later in life thoughif one of a pair of identical twins has schizophrenia the other has a near 50 chance ofbecoming ill too On average people diagnosed with schizophrenia do not receive treatmentuntil three years after the first onset of their symptoms At that point they are typicallyhospitalised after a trip to the accident and emergency department where confused andhallucinating they are given a large dose of antipsychotic medicine Unsurprisingly thosewho first encounter hospitals this way are keen to avoid them thereafter

Researchers are now discovering more about what puts someone at risk of developingschizophrenia or bipolar disorder Some of it has to do with peoplersquos circumstances such aswhere and how they live Combined with cognitive tests and family medical histories suchinformation should make it possible to intervene earlier John Kane of Hofstra North Shore-LIJ School of Medicine in New York has shown that people who receive proper treatment assoon as their symptoms appear recover more quickly and have a less fraught relationshipwith their doctors And they can be treated with far lower doses of antipsychotic medicinethan traditionally prescribed That matters because some of these drugs have unpleasantside-effects including weight gain that discourage people from taking them

Cheer up

But newer sorts of drug treatment look promising too particularly for depression This is themost widespread of mental disorders yet it remains ldquonearly incomprehensible to those whohave not experienced it in its extreme moderdquo wrote William Styron who described his near-fatal encounter with depression in a memoir called ldquoDarkness Visiblerdquo Each afternoon afterfour orsquoclock Styronrsquos head ldquobegan to endure its familiar siege panic and dislocation and asense that my thought processes were being engulfed by a toxic and unnameable tide thatobliterated any enjoyable response to the living worldrdquo

Carlos Zarate at Americarsquos National Institute of Mental Health (NIMH) treats people withsevere depression and bipolar disorder with intravenous ketamine Though often takenrecreationally this is a fairly nasty drug Americarsquos Drug Enforcement Agency has givenwarning that it is being used as a sedative in date-rape cases Those who snort it over anextended period to get a high sometimes find it makes them incontinent Yet to the otherfederal agency that takes an interest in drugs the Food and Drug Administration it looksrather attractive The FDA has given ldquobreakthrough therapyrdquo designation to ketamine as theclosest thing to a miracle cure for cases of severe depression and bipolar disorder

Dr Zarate works with patients who have notresponded to six or seven other forms oftreatment sometimes includingelectroconvulsive therapy Half of the bipolarpatients on whom he has tried the treatmenthad previously attempted suicide Over thecourse of a 40-minute infusion patients losetrack of time hear sounds as if muffled by athick blanket see traces of bright lights and find their thoughts muddled Yet an hour latermore than half of them feel their depression has lifted ldquoThese are patients who a couple ofhours ago were saying lsquoI want to die Irsquom uselessrsquo who are asleep all dayrdquo says Dr ZarateThe effects of ketamine lasts about a week and tests repeating the experiment over a longerperiod are now in process Nobody is quite sure why it works but Dr Zarate hopes that bydoing lots of brain scanning and gene investigation he and other researchers will get a betteridea

Advances in medical technology should also help to keep mental patients out of hospitalDror Ben-Zeev at Dartmouth College has conducted several promising trials using mobilephones to keep an eye on such people In its most basic form this means using text messagesto ask them how they are feeling and remind them to take their medication In a moresophisticated version peoplersquos symptoms are monitored through their smartphones andappropriate care offered If someone is hearing voices telling them not to go outside orsomething terrible will happen says Dr Ben-Zeev a clinician on the other end of an app canask them to try it and see and then report back to him

Since most smartphone users check their devices when they first wake up in the morning andjust before they go to bed those phones can also serve as basic sleep monitors Bouts ofpsychosis are often foretold by irregular sleep patterns A phone can be used to garnerinformation about a patientrsquos physical activity too another useful predictor of distress

What someone does with their phone can alsobe telling Tanzeem Choudhury who works onthis technology at Cornellrsquos department ofcomputer science points out that people in themanic phase of bipolar disorder often go onspending sprees using their phones to shopand gamble If early identification andtreatment can be refined and offered morewidely people with serious mental illness may be able to look forward to a brighter future

Sitting around in a circle with a handful of Dr Kanersquos outpatients at the Zucker HillsideHospital in New York all of them in their 20s and diagnosed with some form ofschizophrenia it is possible to imagine what such a future might look like The hospitalrsquosrooms with their big windows and plywood furniture resemble bedrooms in aScandinavian-inspired business hotel One of the few signs that they are not are thewardrobes with their doors sloping so that nothing can hang from them

Michael who writes poetry and rap lyrics in his spare time has a complicated relationshipwith the voices he hears in his head Sometimes he is able to converse with Voltaire but if hegets no help they can become a deafening 24-hour-a-day cacophony Now he hears them onlya few times a day for a minute or so at a time With luck he should be able to live the rest ofhis life without fear of being locked up in places like St Elizabeths

From the print edition Special report

People who receive proper treatment as soon as their symptoms appear recover more quicklyand have a less fraught relationship with their doctors

What both sides can agree on is that a large number of people with severe mental illness arestill being treated scandalously badly sometimes no better than during the asylum era Partof the old St Elizabeths Hospital has been turned into a new much smaller one bearing thesame name Its best-known patient is John Hinckley who in 1981 shot at Ronald Reagan andhis press secretary Jim Brady who was paralysed by the assault Demand for the hospitalrsquosbeds outstrips availability which means that patients who may need to go into an institutionfor a while are held somewhere else That somewhere else is the DC jail A recent visitor fromthe federal government encountered seriously ill people arrested for minor offences such asurinating in public being held in solitary confinement for 23 hours a day dosed up onsedatives (The prison did not respond to several requests to let The Economist in)

The DC jail is not an isolated example across the country people with serious mentalillnesses are more likely to be in a prison than in a hospital On any given night Cook Countyjail in Chicago houses a couple of thousand people diagnosed as mentally ill a situation thatthe countryrsquos sheriff Tom Dart has described as ldquoan abominationrdquo Rikers Island prison inNew York has become notorious for its guards beating up inmates with mental disorders Butlife for mental patients can be violent outside too the National Sheriffsrsquo Associationestimates that more than 400 people shot and killed by the police in America every year arementally ill

Much of this could be avoided by identifying and treating serious mental illness earlierThere is no single gene that predicts someone will contract such an illness later in life thoughif one of a pair of identical twins has schizophrenia the other has a near 50 chance ofbecoming ill too On average people diagnosed with schizophrenia do not receive treatmentuntil three years after the first onset of their symptoms At that point they are typicallyhospitalised after a trip to the accident and emergency department where confused andhallucinating they are given a large dose of antipsychotic medicine Unsurprisingly thosewho first encounter hospitals this way are keen to avoid them thereafter

Researchers are now discovering more about what puts someone at risk of developingschizophrenia or bipolar disorder Some of it has to do with peoplersquos circumstances such aswhere and how they live Combined with cognitive tests and family medical histories suchinformation should make it possible to intervene earlier John Kane of Hofstra North Shore-LIJ School of Medicine in New York has shown that people who receive proper treatment assoon as their symptoms appear recover more quickly and have a less fraught relationshipwith their doctors And they can be treated with far lower doses of antipsychotic medicinethan traditionally prescribed That matters because some of these drugs have unpleasantside-effects including weight gain that discourage people from taking them

Cheer up

But newer sorts of drug treatment look promising too particularly for depression This is themost widespread of mental disorders yet it remains ldquonearly incomprehensible to those whohave not experienced it in its extreme moderdquo wrote William Styron who described his near-fatal encounter with depression in a memoir called ldquoDarkness Visiblerdquo Each afternoon afterfour orsquoclock Styronrsquos head ldquobegan to endure its familiar siege panic and dislocation and asense that my thought processes were being engulfed by a toxic and unnameable tide thatobliterated any enjoyable response to the living worldrdquo

Carlos Zarate at Americarsquos National Institute of Mental Health (NIMH) treats people withsevere depression and bipolar disorder with intravenous ketamine Though often takenrecreationally this is a fairly nasty drug Americarsquos Drug Enforcement Agency has givenwarning that it is being used as a sedative in date-rape cases Those who snort it over anextended period to get a high sometimes find it makes them incontinent Yet to the otherfederal agency that takes an interest in drugs the Food and Drug Administration it looksrather attractive The FDA has given ldquobreakthrough therapyrdquo designation to ketamine as theclosest thing to a miracle cure for cases of severe depression and bipolar disorder

Dr Zarate works with patients who have notresponded to six or seven other forms oftreatment sometimes includingelectroconvulsive therapy Half of the bipolarpatients on whom he has tried the treatmenthad previously attempted suicide Over thecourse of a 40-minute infusion patients losetrack of time hear sounds as if muffled by athick blanket see traces of bright lights and find their thoughts muddled Yet an hour latermore than half of them feel their depression has lifted ldquoThese are patients who a couple ofhours ago were saying lsquoI want to die Irsquom uselessrsquo who are asleep all dayrdquo says Dr ZarateThe effects of ketamine lasts about a week and tests repeating the experiment over a longerperiod are now in process Nobody is quite sure why it works but Dr Zarate hopes that bydoing lots of brain scanning and gene investigation he and other researchers will get a betteridea

Advances in medical technology should also help to keep mental patients out of hospitalDror Ben-Zeev at Dartmouth College has conducted several promising trials using mobilephones to keep an eye on such people In its most basic form this means using text messagesto ask them how they are feeling and remind them to take their medication In a moresophisticated version peoplersquos symptoms are monitored through their smartphones andappropriate care offered If someone is hearing voices telling them not to go outside orsomething terrible will happen says Dr Ben-Zeev a clinician on the other end of an app canask them to try it and see and then report back to him

Since most smartphone users check their devices when they first wake up in the morning andjust before they go to bed those phones can also serve as basic sleep monitors Bouts ofpsychosis are often foretold by irregular sleep patterns A phone can be used to garnerinformation about a patientrsquos physical activity too another useful predictor of distress

What someone does with their phone can alsobe telling Tanzeem Choudhury who works onthis technology at Cornellrsquos department ofcomputer science points out that people in themanic phase of bipolar disorder often go onspending sprees using their phones to shopand gamble If early identification andtreatment can be refined and offered morewidely people with serious mental illness may be able to look forward to a brighter future

Sitting around in a circle with a handful of Dr Kanersquos outpatients at the Zucker HillsideHospital in New York all of them in their 20s and diagnosed with some form ofschizophrenia it is possible to imagine what such a future might look like The hospitalrsquosrooms with their big windows and plywood furniture resemble bedrooms in aScandinavian-inspired business hotel One of the few signs that they are not are thewardrobes with their doors sloping so that nothing can hang from them

Michael who writes poetry and rap lyrics in his spare time has a complicated relationshipwith the voices he hears in his head Sometimes he is able to converse with Voltaire but if hegets no help they can become a deafening 24-hour-a-day cacophony Now he hears them onlya few times a day for a minute or so at a time With luck he should be able to live the rest ofhis life without fear of being locked up in places like St Elizabeths

From the print edition Special report

But newer sorts of drug treatment look promising too particularly for depression This is themost widespread of mental disorders yet it remains ldquonearly incomprehensible to those whohave not experienced it in its extreme moderdquo wrote William Styron who described his near-fatal encounter with depression in a memoir called ldquoDarkness Visiblerdquo Each afternoon afterfour orsquoclock Styronrsquos head ldquobegan to endure its familiar siege panic and dislocation and asense that my thought processes were being engulfed by a toxic and unnameable tide thatobliterated any enjoyable response to the living worldrdquo

Carlos Zarate at Americarsquos National Institute of Mental Health (NIMH) treats people withsevere depression and bipolar disorder with intravenous ketamine Though often takenrecreationally this is a fairly nasty drug Americarsquos Drug Enforcement Agency has givenwarning that it is being used as a sedative in date-rape cases Those who snort it over anextended period to get a high sometimes find it makes them incontinent Yet to the otherfederal agency that takes an interest in drugs the Food and Drug Administration it looksrather attractive The FDA has given ldquobreakthrough therapyrdquo designation to ketamine as theclosest thing to a miracle cure for cases of severe depression and bipolar disorder

Dr Zarate works with patients who have notresponded to six or seven other forms oftreatment sometimes includingelectroconvulsive therapy Half of the bipolarpatients on whom he has tried the treatmenthad previously attempted suicide Over thecourse of a 40-minute infusion patients losetrack of time hear sounds as if muffled by athick blanket see traces of bright lights and find their thoughts muddled Yet an hour latermore than half of them feel their depression has lifted ldquoThese are patients who a couple ofhours ago were saying lsquoI want to die Irsquom uselessrsquo who are asleep all dayrdquo says Dr ZarateThe effects of ketamine lasts about a week and tests repeating the experiment over a longerperiod are now in process Nobody is quite sure why it works but Dr Zarate hopes that bydoing lots of brain scanning and gene investigation he and other researchers will get a betteridea

Advances in medical technology should also help to keep mental patients out of hospitalDror Ben-Zeev at Dartmouth College has conducted several promising trials using mobilephones to keep an eye on such people In its most basic form this means using text messagesto ask them how they are feeling and remind them to take their medication In a moresophisticated version peoplersquos symptoms are monitored through their smartphones andappropriate care offered If someone is hearing voices telling them not to go outside orsomething terrible will happen says Dr Ben-Zeev a clinician on the other end of an app canask them to try it and see and then report back to him

Since most smartphone users check their devices when they first wake up in the morning andjust before they go to bed those phones can also serve as basic sleep monitors Bouts ofpsychosis are often foretold by irregular sleep patterns A phone can be used to garnerinformation about a patientrsquos physical activity too another useful predictor of distress

What someone does with their phone can alsobe telling Tanzeem Choudhury who works onthis technology at Cornellrsquos department ofcomputer science points out that people in themanic phase of bipolar disorder often go onspending sprees using their phones to shopand gamble If early identification andtreatment can be refined and offered morewidely people with serious mental illness may be able to look forward to a brighter future

Sitting around in a circle with a handful of Dr Kanersquos outpatients at the Zucker HillsideHospital in New York all of them in their 20s and diagnosed with some form ofschizophrenia it is possible to imagine what such a future might look like The hospitalrsquosrooms with their big windows and plywood furniture resemble bedrooms in aScandinavian-inspired business hotel One of the few signs that they are not are thewardrobes with their doors sloping so that nothing can hang from them

Michael who writes poetry and rap lyrics in his spare time has a complicated relationshipwith the voices he hears in his head Sometimes he is able to converse with Voltaire but if hegets no help they can become a deafening 24-hour-a-day cacophony Now he hears them onlya few times a day for a minute or so at a time With luck he should be able to live the rest ofhis life without fear of being locked up in places like St Elizabeths

From the print edition Special report

Since most smartphone users check their devices when they first wake up in the morning andjust before they go to bed those phones can also serve as basic sleep monitors Bouts ofpsychosis are often foretold by irregular sleep patterns A phone can be used to garnerinformation about a patientrsquos physical activity too another useful predictor of distress

What someone does with their phone can alsobe telling Tanzeem Choudhury who works onthis technology at Cornellrsquos department ofcomputer science points out that people in themanic phase of bipolar disorder often go onspending sprees using their phones to shopand gamble If early identification andtreatment can be refined and offered morewidely people with serious mental illness may be able to look forward to a brighter future

Sitting around in a circle with a handful of Dr Kanersquos outpatients at the Zucker HillsideHospital in New York all of them in their 20s and diagnosed with some form ofschizophrenia it is possible to imagine what such a future might look like The hospitalrsquosrooms with their big windows and plywood furniture resemble bedrooms in aScandinavian-inspired business hotel One of the few signs that they are not are thewardrobes with their doors sloping so that nothing can hang from them

Michael who writes poetry and rap lyrics in his spare time has a complicated relationshipwith the voices he hears in his head Sometimes he is able to converse with Voltaire but if hegets no help they can become a deafening 24-hour-a-day cacophony Now he hears them onlya few times a day for a minute or so at a time With luck he should be able to live the rest ofhis life without fear of being locked up in places like St Elizabeths

From the print edition Special report