From the Studio – Mental Health in America: New Directions for Care and Connection

David Cutler: Hello. I'm David Cutler, Dean of Social Sciences in the Faculty of Arts and Sciences at Harvard. Thanks for joining us for this second installment of our From the Studio series. Here, we engage our world class experts on topics of critical importance to the nation and world.

I can't think of anything more pressing than the global mental health crisis we're living through, with rates of suicide up 35% in the United States over the past two decades. There are sharp increases over the same period in rates of anxiety and depression, with the trend lines particularly alarming when it comes to youth. Today's panel features four of the university's top authorities on mental health, depression, anxiety, and trauma. The depth and breadth of the expertise they offer is unique to Harvard.

The panel will speak on whether the US is experiencing a loneliness epidemic and mental health crisis. They'll wrestle with the impact of new technologies and discuss how they're harnessing the power of smartphones and chatbots to improve, rather than harm, mental health. We put out the call for viewers to submit questions in advance of today's event. If you missed the window today, keep an eye out for future installments in this series when you'll have more chances to pose questions to our faculty experts.

I'd now like to introduce our exceptional moderator, Al Powell. Al is senior science writer for the Harvard Gazette. In his time at Harvard, he's written about topics as diverse as AI in medicine, loneliness and depression, and the science of love. Al has also taught journalism for more than 10 years at the Harvard Extension School. Al, the floor is yours.

Al Powell: In 2021, the US surgeon general called attention to declining mental health among America's youth, citing a 2019 study showing one in three high school students and half of female students had persistent feelings of sadness or hopelessness, a 40% increase from 10 years earlier. In 2023, the surgeon general called attention to an epidemic of loneliness and isolation among Americans of all ages and backgrounds, with some telling him on a listening tour, if I disappear tomorrow, no one will even notice. Other warnings aren't hard to find.

The World Health Organization in September said that more than a billion people worldwide are living with mental health conditions. A Gallup poll in March found that the pandemic-era decline in US mental health has lingered in the years since. And another in September found that the percentage of US adults who currently have or are being treated for depression was at the highest level since initial measurements in 2015, a level that's been stagnant for two years.

Several things have gotten the blame. The COVID-19 pandemic severed connections between people and fostered an environment of fear, uncertainty, and isolation. But the trends that the pandemic exacerbated predate it and may have roots and shifts in how we live, work, and interact.

Technology's impact on our lives has become an inescapable part of any mental health discussion. It's put information at our fingertips, enabling greater connection over large distances, even as it pulls us away from the here and now. A new generation of artificial intelligence seems destined to change how we learn and work, even as we struggle to adapt to past changes. Technology helps, as well. Our phones keep us mindful and help us meditate, and our watches monitor our bodies in ways that not long ago required a visit to the doctor's office.

Welcome to From the Studio, a symposium series from FAS. Today, we'll explore our fraught and rapidly changing mental health environment. Our accomplished panelists have deep insights into how we got here, and are exploring new approaches that may lead to badly-needed improvements.

Elizabeth Lunbeck is a historian of psychiatry, psychology, and psychoanalysis, and chair of the Department of the History of Science at Harvard University. She's the author or editor of seven books in the field, and is currently at work on the forthcoming The Therapist, a Short History from Freud to ChatGPT. She recently led a general education course called Psychotherapy and the Modern Self, introducing hundreds of students to the full range of therapeutic modalities from the analytic to the behavioral, and focuses on the challenges and opportunities posed by the new AI platforms. Lunbeck is also particularly interested in personality disorders, especially narcissism and borderline personality disorder.

Karestan Koenen is a clinical psychologist, epidemiologist, and author. She is a professor of psychiatric epidemiology at the Harvard TH Chan School of Public Health and an institute member at the Broad Institute of MIT and Harvard, where she directs the Broad Trauma Initiative. Koenan's research examines why some individuals are resilient, while others develop PTSD and related health problems following trauma, the long-term effects of violence and trauma on mental and physical health, and how to expand access to evidence-based treatments for survivors.

Jordan Smoller is a psychiatrist, epidemiologist, and geneticist with a research focus on understanding the genetic and environmental determinants of psychiatric disorders across the lifespan, and using big data to advance precision medicine. Smoller is a professor of psychiatry at Harvard Medical School, and professor in epidemiology at the Harvard TH Chan School of Public Health. At Massachusetts General Hospital, he is the Gerald F Rosenbaum Endowed Chair in Psychiatry, Director of the Center for Precision Psychiatry, Director of the Psychiatric and Neurodevelopmental Genetics Unit in the Center for Genomic Medicine and co-director of the Center for Suicide Research and Prevention at Massachusetts General Hospital and Harvard.

Matthew Nock is the Edgar Pierce Professor of Psychology at Harvard University, and the co-director of the Center for Suicide Research and Prevention at Massachusetts General Hospital in Harvard. He also holds appointments as a professor of epidemiology at the Harvard TH Chan School of Public Health, and is a research scientist at Mass General Hospital and Boston Children's Hospital. His research is aimed at advancing our understanding of why people behave in ways that are harmful to themselves, with an emphasis on suicide and other forms of self-harm. He uses a multidisciplinary approach to better understand how these behaviors develop, how to predict them, and how to prevent their occurrence. In 2011, Nock received a MacArthur Fellowship in recognition of his work.

I clearly have a very accomplished panel here, and welcome to you all. Hopefully, over the next hour, we're going to have an interesting discussion on one of the nation's major challenges facing it. So when we talk about a mental health crisis in America, what are we really talking about? We hear a lot about anxiety and depression. Is this an anxiety and depression crisis, is this a loneliness crisis, or is it across the board to things like bipolar disorder and schizophrenia?

Karestan Koenen: I would really say it's a loneliness, anxiety, and depression crisis. We haven't seen increases in bipolar disorder and schizophrenia. I mean, Jordan's more of an expert on that. Although we've always had a crisis in care of those disorders. There's many people that are suffering from those disorders who don't receive adequate care, and we have a crisis in treatment in that the efficacy of the treatments for those conditions has been problematic in terms of side effects of medications, people being able to get the best treatment.

Jordan Smoller: Yeah, I would agree with that. I think part of the reason we haven't seen a change, perhaps, in some of these other conditions is they haven't been as well-studied as anxiety, and depression, and loneliness. We've really had a focus on that lately, which is great. But I think we don't really know.

Some of the big studies that have been done that document what is the frequency of different conditions, many of the best studies, it's been a while since they've been updated. There's a little bit of positive silver lining kind of news from the latest national survey on drug use and health, which suggests that for some things we're seeing either a plateau or maybe even a decline-- things like alcohol use disorders, a little bit of a decline in depression among young people. But mostly, it's a plateau at this point, I think.

Elizabeth Lunbeck: And I've seen some evidence from American Psychiatric done last May, a survey showing that the rates of loneliness have declined. You'll notice that the data of 2021, which was in the middle of the pandemic, was when the loneliness epidemic was named as such. Now, still, one in three Americans feel lonely.

It's still very high.

Matthew Nock: It's very high, but it's not as high as it was during the pandemic because we've reinstituted social life.

And I think that nuance is important, and the zooming-- how are we going to zoom in and out? So a lot of these things-- depression, anxiety, suicidal thoughts and behaviors-- have been increasing in recent years. But if you zoom out, they've been there for a long time, and they've been big problems for a long time. You think about the suicide rate, it's increased in the past two decades, but the suicide rate now is virtually identical to what it was 100 years ago.

Oh, wow.

So we see a little ebbing and flowing over time. But when you zoom out, you see it's been a problem for a long time. So a recent epidemic, but more general global problem.

Karestan Koenen: And as well, we've known for a long time-- I mean, as long as we've had community studies of mental health-- that there's a huge gap between need and treatment. I mean, that we've probably known for 100 years, so that is also not new.

Al Powell: And when you talk about the suicide rate being the same as 100 years ago, has it been steady? So is this kind of a steady thing, or has it gone way up and down?

Matthew Nock: Yeah, it's increased the past two decades. It was coming down the two decades before that, and we don't have a good understanding of exactly why we see the ebbs and flows. We also see demographic differences. So the rate in young people has been increasing pretty consistently over time. Whereas for older people, it's been coming down. And so a lot of the work that researchers in this area are doing is trying to understand, well, what's leading to these increases and decreases, and can we harness those and help convert those into more prevention and intervention efforts?

That's really interesting.

Al Powell: The downward trend in mental health started before the pandemic, but clearly, the pandemic made everything worse. We're several years past the pandemic. How long is this pandemic tail going to be? One of the polls that we talked about in the introduction was the Gallup poll that said we're still kind of feeling the effects of the mental health impacts of the pandemic.

Jordan Smoller: Well, as I said before, there's a little bit of a plateauing now, and in some places, a little bit of a decline in terms of some of the mental health symptoms. It's easy in some ways to blame the pandemic, in a way, for a lot of what's been going on. But as we said before, these are trends that have been going on before. And a lot of things that have happened around the time of the pandemic are also, we think, relevant to the nation's mental health-- things like the disconnections, the polarization, potentially the use of technologies that in some cases may exacerbate disconnection, and so on.

So those things are not going away. So that concerns, I think, a lot of us.

Karestan Koenen: Other things like increase in mass shootings. Other people have documented declines in community participation, whether religious attendance, but participation in community organizations. That also has been declining since about 2010, although I think that's changing a bit now, too.

Now there's—

Elizabeth Lunbeck: As a historian, it's really important to take the long view. So the 1919 pandemic appears as-- if it appears at all in textbooks as one sentence. So will we remember the pandemic? How will we remember it in 10 years, 20 years? How will we measure the effects?

So we're still in the aftermath. So it's really hard to say, and I think that's what everybody's saying. We just don't know really well.

Matthew Nock: And there's nuance in, we should acknowledge, in how it affected people differently. So as many others do, we do work where we monitor people's mental health with smartphones and related technologies, and we started this before the pandemic. And interestingly, we saw during the pandemic, everyone was staying home nearly 24 hours a day. We have GPS trackers with people's consent, and feelings of loneliness skyrocketed. And with that, suicidal thoughts increased. In people who felt more isolated, they thought about suicide more.

We saw this in adults, not in adolescents. They seemed to respond, at least initially, not so bad being home, being out of school, and so on. But that changed over time.

Introverts did better early in the pandemic than extroverts. So you can think about why that might be-- people who had more money versus less money. So the pandemic wasn't one big monolith. It affected people in really different ways, and how long that's going to last is still something we're trying to tease out.

Al Powell: When we look at that differential of how people are impacted, are you expecting a big divide between adults who had their way of behaving before the pandemic, went through the pandemic, changed their behavior, and came out, and went back to that, and kids who socialization is important in school. Some especially younger kids missed a couple of years of school. Is that when we talk about a long tail or a short tail of the pandemic, is that important in your thinking about mental health? Are these kids, when we see problems coming among the younger generation, or are they just too young to be affected, to be measured yet, even?

Matthew Nock: I think it's a good empirical question. I mean, we see changes in test scores during the pandemic. So we see school performance was affected, and increases in anxiety and depression we see in kids, as well. And you think about critical periods. And when kids are learning how to interact and how to socialize with others, learning how to be exposed to alcohol and drugs during adolescence, and manage those things in their environment.

And now, we have a cohort of kids coming through who had a very different experience, and we're still learning how that's playing out as adolescents reach adulthood, younger kids reach the middle school years, and so on. So I think we don't know the answer yet, and we're having a real-time quasi-experiment.

Karestan Koenen: And I think also social context plays a role, and there's been some interesting studies where they've looked across-- there was a study that did helpline calls globally and found that they were influenced-- they went up with lockdown or stay at home orders, but they decreased in places that did income support for their communities or their population. And so there are influences, not just local communities-- things were very different. I live in Massachusetts, but I have family in Georgia. Things were very different in Georgia in terms of what was open, what was closed.

And so in addition to saying each individual had their own-- I have a friend who says everyone had their own pandemic, but each family's individual, there's also these macro social forces that shaped people's experience. And places where there was more income support and economic support, there is some evidence that that might have buffered some of the mental health effects, too.

Yeah, we-- oh I'm sorry.

Elizabeth Lunbeck: Go ahead. Well, I was going to say the mass death. We have not memorialized it. 55,000 soldiers died in Vietnam. A million Americans died. We don't talk about it.

Exactly.

There's this un-processed, metabolized trauma just out there.

Karestan Koenen: I was thinking that. I mean, I was in New York on 9/11, and there's a memorial for 9/11. But I think even myself, I find myself not wanting to read books and see things about the pandemic. I just want to move on. So I also think there's a process-- we're past it, but we haven't gotten over it. We haven't really processed the loss.

Al Powell: And you wonder, where's the great book, or the great movie about the pandemic?

Karestan Koenen: And I don't even know if I want to watch it.

Elizabeth Lunbeck: I feel the same. I think people just don't want to--

Al Powell: Because you know there's great stories there.

Elizabeth Lunbeck: Yeah, right.

We don't want to hear about it.

Karestan Koenen: We don't want to hear about it, but we'd rather be angry with each other about it.

Al Powell: So whenever mental health comes up, inevitably technology becomes part of the conversation. AI powered chat bots are the newest kid on the block, and they're powerful tools, clearly. That also provides supportive near-human interactions.

Several cases have grabbed headlines, though, of potentially negative impacts of these chatbots, even where they've been accused of encouraging suicide. What's your sense of those cases, and how closely do we need to monitor these chatbots for harmful interactions?

Jordan Smoller: Yeah, I'm curious to hear Liz's take on the history of these things. As I think about new technologies, I think about old technologies. And a lot of the conversations that we're having now about chatbots we had a few years ago about social media. We had a few years before that--

We've had about TV probably.

--TV, and telephones, and so on. They were tools. Are these tools good or bad? Well, they can be used like a sharp implement for saving life in surgery or homicide.

So I think we're still, for each of them, we've got to figure out how do we use them in a way that maximizes the good and that minimizes the harm. And I think the same arguments and the same approaches are playing out now in social media and large language models. But Liz, this is your discipline.

Elizabeth Lunbeck: I appreciate the nod to history. I'll bring up another data point, if you will. The first chatbot for mental health was the Eliza machine, which was set up by Joseph Weizenbaum, a computer scientist at MIT, and he found immediately that people reacted to the chatbot, to the machine, to the Eliza, as if it were a person. And there's an apocryphal story of him-- his secretary was using it in the interface, and asked him to leave the room because she was having a private conversation with the chatbot. And even his colleagues who were computer scientists, he complained that they should have known better. So still, there's something very alluring about this technology that we don't fully understand yet all these years later.

Jordan Smoller: Well, we're prepared to attach in many ways, right?

Yes.

So the chatbots are increasingly very good at tapping into some of the machinery that we have ourselves in terms of identifying a connection with something and then anthropomorphizing it.

Elizabeth Lunbeck: People talk about it-- them hacking our attachment system.

Oh, interesting.

And there's been studies, very recent, showing that-- well, there's been a lot of focus on the sycophancy, the way that they are primed to agree with us, to mirror us. But a recent study was just reported that the yes answers from ChatGPT outnumbered the no-- yes answers outnumber the no answers by 10 to 1. So there is something there. On the other hand, people are using them in ways that I think we can't dismiss. We have to be curious about how they're using them.

Matthew Nock: I also, though, what are we comparing them to? So we three are licensed clinicians. I think, to how I learned to do therapy in the room as human to human, I say yes a lot more than I say no. I do a lot more validating. We're trained, and the evidence suggests, there's benefit to validating a person's experience, yes and.

I rarely, when I do therapy, say, no, you're wrong, and don't do that. So I think we've got to think about, well, what's the right comparison condition?

Exactly.

Elizabeth Lunbeck: Well, Freud said the therapist-- I mean, way back when, Freud said the analyst should be as a mirror to the patient. And now, we complain about chatbots mirroring, but that is part of what therapists do.

Matthew Nock: This, too, is Freud's fault.

[LAUGHTER]

I also think we should acknowledge the positive here. So we started talking about the pandemic and the mental health epidemic, or however the long tail is. There's a lot of-- in the country, in the world-- what epidemiologists call unmet need. So there's a lot of people who have mental disorders, struggle with mental disorders, and don't have the access to care.

Elizabeth Lunbeck: That we've known forever. I mean, as long as we've taken data.

Matthew Nock: And here comes a technology that a lot-- not everyone, but a lot more people have access to. And so the possibility, the upside here, I think is really great. It's really incredible.

Elizabeth Lunbeck: And it's free.

Matthew Nock: And it's free.

And it's free. So far.

Elizabeth Lunbeck: So far.

Al Powell: And available at 2:00 in the morning.

Right, always available.

Crisis moments, you don't have to wait for an appointment.

Jordan Smoller: And also, it's moving so quickly that what we're seeing now with chatbots a couple of years from now will be--

Even-- probably even six months from now.

Right, they'll be much more probably anthropomorphic interactions. And I think there is a lot of possibility for good because-- and you can chime in on this, perhaps-- but we know something about the active ingredients of effective psychotherapy across psychotherapies. I mean, there are some core things that seem to be essential regardless of the particular school of thought, or ideology of a particular therapy, and those are things that you could-- if you wanted to, and I think some people are-- build into these kind of interactions, a sort of supportive, curious interaction, empathy, at least to some degree, learning new skills, and being able to impart that, and following up. I mean, there's some basic core things that would be pretty amenable, I think, to this kind of interaction.

Karestan Koenen: And also, there's a lot of people doing work on having technology support, for example, rather than us, who had to go to school a million years to become licensed professionals, support community health workers. This is the kind of work we do and other people do in the African context, in Kenya and Uganda. For ages, people have been training community health workers, people who don't have a college education, to do mental health work, particularly around conditions like anxiety, depression, and now supporting them with technology and/or using apps.

And we've been resistant to doing that in the US for all kinds of reasons, but I think we could learn a lot from that. And also, the technology could be used to support people in the health care system or in different systems to deliver these effective parts of psychotherapy, or support their work.

Al Powell: Are they ready for prime time when we hear about these troublesome cases? It seems you guys are in agreement that there's great promise here, but are they there yet?

Elizabeth Lunbeck: Well, you can talk about suicide, but obviously, we need better guardrails, and the companies are talking about that. I mean, there's an illusory relationship. It is a relationship. And for a long time, for almost 100 years, we've known that relationship is the key to effective psychotherapy.

So people have said, well, it's not a relationship with a human, but I'm more focused on what's the nature of that relationship people are forming with the chatbot? In what ways does it matter? In what ways doesn't it matter that it's not human?

And if you believe-- if it's giving you something useful that you didn't have before, who are we to say--

Karestan Koenen: Is that better than nothing?

Elizabeth Lunbeck: Is that better than nothing? If it's preventing you from seeking help, that's a problem. If it's responding to your suicidal ideation with, yay, go, girl, that's terrible. So you probably have thought about this.

Karestan Koenen: And do they know-- I mean, do they know, or do you know if people are using these instead of, they're replacing other things? We don't know. Or if it's people who wouldn't reach out at all, and they're reaching out to AI? We don't know, OK.

Elizabeth Lunbeck: I mean, there must be in some way in which-- because the numbers--

Are so high.

800 million users a week.

So some of the-- OK.

Matthew Nock: I see this, as in many areas of health and medicine, there's an iteration that has to happen. And think about, are we ready? Is the treatment ready?

There are people dying now. You think about cancer, is the treatment ready? Well, people are dying today. People are dying yesterday. So let's get the best treatment we can in the hands of people, test it out through the scientific process, see what works, and see if we can make it more, and more, and more effective.

I think the same approach is needed here. We have people who need help now. And a lot of these platforms weren't designed to provide therapy, but people are using them for a pseudo-therapeutic kind of relationship. So the people are saying, I need help, and I'm going to this technology, these large language models, for help, and are getting it. How can we work together to make it more effective and iterate over time? So I'd love to see more collaboration between industry and independent scientists to work together to iteratively improve these technologies in ways that improve the health of society.

Al Powell: The scientists at Dartmouth have taken the lead on this, and they've developed Therabot. So it's a chatbot that has been trained by clinical psychologists, and psychiatrists, and folks who know what they're doing to provide validated answers. And there was a recent study that showed that it provides clinically meaningful-- I don't know if care is the right word, but it does pretty good.

Elizabeth Lunbeck: But I don't want to lose sight of the dangers, though, because you did start with that. And I think there has to be more attention to regulation and more pressure on the companies.

Who does the regulation, though?

Well, states or federal. So for Illinois has outlawed, apparently, chatbots for therapy. But it's kind of a semantic question. What's therapy, and what's emotional support?

But there are ways to-- if you've been on it for five hours, for the bot to say, maybe you should take a break or something like that. So there are ways to build in some guardrails, and we just have to keep pressure on the companies to do that.

Al Powell: And you have situations that there was a piece in the New York Times last week about people who have romantic relationships with chatbots. Some of them are married, and it's in full knowledge-- with the full knowledge of their spouses. Is there anything inherently wrong with that, or is that-- we're talking about--

Elizabeth Lunbeck: Well, I read a lot of the comments on that article, and people are like, no, no, no, no, no. But as I don't want to be normative here, I just I think it's an interesting phenomenon. And people brought up, well, men have always been looking at porn. What's wrong with women having fantasy boyfriends? I just want to know more about what's actually going on.

People are lonely, and they're finding something here. We don't have to approve of it or disapprove, but it's an interesting problem. I'll just take that out.

Al Powell: Would it be preferable if we boosted human-- got people we weren't bowling alone anymore, to reference an important work in that area? Or is that 1960s thinking?

Jordan Smoller: You need to make people-- to foster more connection. Yeah, I think unequivocally, one of the things that we've studied, and others as well, looking for, what are the factors that are likely to be causally protective against developing things like depression? And over and over, two things come up. One of them is physical activity, and the second one is social connection.

And during the pandemic, we had a study in which people who had good social and emotional support early in the pandemic had half the rate of developing significant depression. And so I think absolutely, it's a difficult thing to do. Our society is being structured, I think, in the opposite direction too much.

Karestan Koenen: And you've had studies, I know, where you've looked at people at high genetic risk of depression in the military, and found that those with in units with high support, high conviction in their military units, even though they had high risk of depression genetically, had less new depression later. So even with high genetic risk, the social support and connection can buffer against that.

Jordan Smoller: It's protective.

Karestan Koenen: Protective. So I agree with that.

Elizabeth Lunbeck: So with this woman who was profiled, it was interesting also that she shared her experience with her friends. So it might have been added on to--

It wasn't just alone.

It wasn't a replacement for it. I mean, there was a lot of time she spent alone with the chatbot. Her husband was living in a different country and so on, but she did also, as women tend to do, talked a lot with her friend group about what was going on. So I found that as a interesting subtext.

Interesting.

Yeah. I mean, people have different needs and desires.

Al Powell: And when we talk about technology, one technology we're still adapting to as our head's spinning here with these large language models exploding on the scene, but there's still schools that are talking about whether or not they should have cell phones in the schools. And social media often gets identified as a source of bullying and other harmful impacts on children. Do you guys know of this technology being used for good? There's apps, as-- meditation apps, things like that. Are there innovative things going on in that area that you know of?

Matthew Nock: Absolutely. I would come back to the idea of these are tools, and they can be used for good and evil. And we actually did a study at Harvard a few years back now where we interviewed teens who were getting psychiatric treatment, and we asked them about their social media use and what is helpful, what is harmful. And we saw pros and cons, perhaps not surprisingly. Some-- actually, not some-- everyone said, there are aspects of it that I love. I connect with other people.

I see what the new trends are. I learn skills that I can use for my mental health. And on the negative side, I do social comparison, and I feel lonely, and I feel like I don't have enough, and kids bully me, and so on.

So kids are using social media. This is the world they're living in, and there's good things happening and bad things happening. So I wouldn't say it's bad, or phones are bad, or televisions are bad, or telephones are bad. There are some good and some bad that can be done, though it's more nuanced than that. There's, how do we find out how to maximize health and minimize harm?

Karestan Koenen: And we have a study where we're doing an app-based treatment-- this is in a place we work in Kenya-- for PTSD. And we're finding-- I was a little skeptical. We're finding really positive effects. People's PTSD symptoms are really going down with this mainly app-based treatment, and they meet occasionally with a facilitator.

And that's by people's smartphones, not something we could have done a decade ago. And it's reaching many more people than we could have reached if we were waiting for a therapist trained in the specific evidence-based treatment to see individual patients in their office. So that's also something promising.

Jordan Smoller: Yeah, I that's really promising. I think social media is not going away. The numbers I've seen are that 75% of young people get mental health information from social media, and there's room for raising the game there. I worry about that a bit because there's so much misinformation and investment, in some ways, in psychiatric illness as being an important part of people's development, and a lot of expression of people's distress through the labels of psychiatric illness, and often inappropriately. And so it's another thing that I think we have to keep our eye on because so many people really are-- that's where people are getting their information, and it's not always good.

Elizabeth Lunbeck: I couldn't agree more. I mean, it's become a marker of identity. Through TikTok, there are whole communities around entities that aren't in the DSM, but that have been named by users. And we have to think about other ways for people to express their emotional vulnerabilities and concerns.

Jordan Smoller: Yeah, I mean, from a historical perspective, I would think you would know this better than I. But in the '80s and '90s, there were disorders that became very common-- multiple personality disorder. People began to see their experience through the lens of these things, and they—

Elizabeth Lunbeck: They sharpen, and they give you a community, which are-- the community is a good thing. But if it's a destructive community—

Jordan Smoller: Right. And those diagnoses go up and down as people find new idioms, and some ways to express themselves.

Matthew Nock: And there are ways to embed, as Karestan was saying, good in them, and to do experimentation. We teamed up with an industry partner who developed an algorithm to find people online on social media platforms who were in distress, and then we experimented with how do we get them to crisis services? And we found that through a little tweak, we could boost use of crisis services by about 25%.

I worked with another platform to find blog posts that people found really helpful and inspiring, and then randomized people to get those versus not. And found that people who got these blog posts had a significant decrease in their suicidal thinking, and they felt more hopeful, more optimistic, more connected with others. So there are ways to use platforms and new technology in ways that, again, boost people's mental health rather than decline it.

Karestan Koenen: We need a Yelp for mental health, where you go on Yelp and you're finding, where's the best lunch spot? And would actually drive you to evidence-based support. But that would be accessible and attractive to young people, because often I feel like I have an 18-year-old son. And I just feel like I am so out of date in relation to his relationship to technology, having grown up with it. But if there was a way to drive people to the best mental health services, the best information when they did searches, I'm sure, just like you can maximize the best lunch spot, or the best coffee place.

Matthew Nock: I don't think the [INAUDIBLE] using Yelp, though, anymore. You could do, like, TikToks.

Karestan Koenen: I know. I don't even-- I'm not on any social media, so I'm the-- yeah, Yelp. The kids are all like, what's Yelp? Yeah, I know.

Al Powell: But we can identify these sites, and we can tell that they're working for the ones we're using them. But how do we get that out?

Karestan Koenen: How do we connect people with them through AI or whatever?

How do you cross that gap? Is there—

Al Powell: How is it weighted in the-- I don't-- that's exactly.

Karestan Koenen: Is that something that you reach out to the people who run TikTok to change the algorithm a little bit, or something like that?

Matthew Nock: I mean, the one exciting thing here is that work is happening so much more quickly. Studies are getting done more quickly. We're learning more quickly than we did 10 years ago, 20 years ago, when we were going out into the field and giving people paper and pencil surveys to understand how they're doing. Now, we can learn how people are doing really quickly and intervene really quickly.

The study I mentioned with boosting crisis services, we did that study in five weeks on 40,000 people. So it was really fast data collection, really fast experimentation.

Al Powell: Now Jordan, you're working on something called precision mental health. I know it's just a phrase and there's lots of work beneath it, but that's intriguing to me. What does that look like?

Jordan Smoller: Well, the idea of precision psychiatry, precision mental health is bringing precision medicine approaches. And precision medicine is really the idea that we pay attention to individual variability, individual differences in our genes, behavior, lifestyle, environment to do better in how we diagnose, or treat, or prevent disease. So that can include a number of things, and it's a very exciting time. Because just in the last 10 years, we've seen the advent of some of the things we just talked about-- AI-- but lots of other scientific advances, and scaled data, and tools in basic neuroscience that we really did not have. And so that opens up a lot of possibility.

So the idea of precision-- psychiatry is often said to be delivering the right treatment, or intervention, or strategy to the right person at the right time. Most of the treatments that we have, which are very helpful for many people, and sometimes they're life saving, they don't work for everybody. And they're based on what works for the average person. And none of us is the average person because we're all unique.

And so the idea of precision psychiatry is, let's understand the variability, the heterogeneity, and try to tailor what's really going to be most helpful to this individual. It also can involve things like discovering new treatment modalities. Advances in genetics-- an area I'm very interested in-- have really been remarkable in the last decade, and pointed us to new biology that's relevant to these disorders. That can then, in turn, generate new targets for treatment development.

So I think we're going to see a lot of that. It's an approach that's worked dramatically in certain other areas of medicine-- oncology, cardiology, and so on.

Al Powell: Yeah, lots of promise there. And there's still a lot that's unknown about these conditions in a biological level. And Karestan, you're working in the Broad Trauma Initiative with trauma and the roots of trauma, right?

Karestan Koenen: Yeah. So what we're working on is we've known for a long time that experiences of trauma, and what I mean violence, disasters, serious accidents are related to not just PTSD and mental health conditions, but chronic disease later in life. My group and other groups have published, for example, on women's experience of stalking related to her development of cardiovascular disease decades later. And so the Broad Trauma Initiative is bringing-- so Jordan and I work at-- we're both affiliated with the Broad, and it's made major advances in genomics and genetic medicine.

It's bringing this big science approach to understand how the environment, starting with the adverse environment, gets in our bodies and causes disease. And also, traumas related to so many different diseases. Is there some common biology across them? But also moving towards a more personalized medicine approach because we know that these experiences of trauma in some people will lead to some of these different diseases, but we don't know how to say-- we don't know how to detect that early or know what's going to happen with whom. And so it's getting at some of those questions, too, at a large scale.

Al Powell: And when we think about the future, when we think about where your work is going to lead, and really all of yours, how do you see mental health care changing in 10 years?

Jordan Smoller: Well, I think the big problem with mental health care, probably, that dwarfs most others is access to care. And that's a problem that is multi-determined. A lot of different financial, social, political, but also in terms of mental health specialties, there is a workforce shortage. Some of the things we talked about might help with that-- new ways of delivering care, peer to peer care, or maybe AI assisted care.

So we have to solve that problem. There are way too many people who are not getting the help that they need, people with serious mental illness. People with serious mental illness, psychotic illness and so on, actually have a shortened lifespan of 10 to 15 years. I mean, it's staggering. And we don't really-- we're not jumping on that, I think, in the way that we need to.

So access and quality care is crucial. My hope also is that we're going to advance into this possibility of more precise, personalized treatment that's actually more effective and less-- easier to tolerate, or reaches people where they are and where they need to be. And, I hope, a much bigger focus on prevention and early detection because most of what we do now is reactive. We really need to invest in that.

Elizabeth Lunbeck: So can I jump in on this? For years, it's been the case that about half of the people who seek psychotherapy do not meet the criteria for any diagnosable mental disease. They go for support, for advice, for companionship, for changing oneself-- a whole range of reasons.

Matthew Nock: So there's unmet needs. People refer to that as met un-need, where people go and they get access to care. Maybe they don't need it.

Elizabeth Lunbeck: So they're worried well, in some ways. So from where I sit in therapy communities, there's a lot of worry, will therapists survive this, the new technology? Will there be a role for an actual human-to-human interaction? And I'm a big proponent of things happening when people actually talk to each other. Just post-pandemic, we've seen there's an excitement around Harvard now that there wasn't in the immediate post-pandemic because we're all talking to each other again.

So I'd just like to keep some focus on that. I agree, access is a huge problem, and therapists are very concerned about that. And there is room for these new technologies really addressing a persistent, long-term problem. But I wouldn't want to just completely throw out the having someone in your life that you can talk to problem.

Matthew Nock: Yeah. I think keeping human in the loop-- sorry, go ahead.

Karestan Koenen: Oh, no, you go ahead.

Matthew Nock: OK. I haven't talked to other humans in a while, so I'm not--

[LAUGHTER]

Not used to it. I think there are different targets. One is, we can meet the need that people have who don't have access to care with technology, but we also need to do a better job of seeing people in person. And so figuring out how can humans and technology work together? How can technology help us do our job better?

Thinking about suicide, half of people who die by suicide saw a clinician in the four weeks before they died. So they're getting to care.

Karestan Koenen: There are all those stories that.

Matthew Nock: And the risk of suicide death is highest right after people leave a psychiatric hospitalization. So they were in care. They were in round-the-clock care, and then shortly after leaving, they died. So one of my biggest questions is, and this is a focus of the center that Jordan and I lead at Harvard MGH, is how can we use new technologies to embed into human interactions, to provide better round-the-clock care, reach people when they need it, not in the absence of humans, but in addition to their human connections?

Elizabeth Lunbeck: So using AI to augment, not to replace.

Matthew Nock: Exactly, yes.

Karestan Koenen: And I think the other piece that we need to think about is the brain doesn't exist separate from the rest of the body. And as Jordan mentioned, there actually is really good evidence that exercise can prevent depression. And I think there's pretty-- I would say it's pretty causal evidence. And even in the area I work in, which is post-traumatic stress disorder, I was very skeptical of this.

I do yoga. I do meditation. I do all that stuff, but there's recently been large clinical trials where they've compared a cognitive behavioral therapy-- that's the gold standard for people with PTSD-- against trauma informed yoga randomized. They had the similar effects on PTSD symptoms, and there was less dropout from the yoga.

I would have said, you can't recover from PTSD without talking about your trauma. There was no talk about the trauma in the trauma-informed yoga. So what's going on there? I don't know, but there is this place for other things besides talking.

Maybe it was the community of doing yoga in the group. I mean, that can help people with mental health problems, especially anxiety and depression. I don't want to trivialize people with psychotic disorders or suffering from severe mental illness and say that yoga is going to cure them, but I think there's a lot of exciting developments in mind and body that we don't really understand that could also help address this.

Al Powell: So it may be that a future Dr. Chatbot tells you to shut off the chatbot and go for a run, preferably with a whole group of people.

Elizabeth Lunbeck: Exactly.

Matthew Nock: Why are you still talking to me?

[LAUGHTER]

Al Powell: Very good. So we have some questions from the audience, or that have been sent in over the last few days from our live audience, that we'll get into in the last few minutes of the show. So, like many parents, one listener wrote, I recently read NYU psychologist Jonathan Haidt's book, The Anxious Generation, which details how screens are harming young people. I'm curious what the panelists make of the book and its claims. Should parents be limiting screens in our children's lives?

What about our teenagers' lives? Should we be pushing our public schools to curb laptop-based curriculum? There's about three questions. We can merge them into one, but go.

Karestan Koenen: One question is parents should be limiting screens in their own lives. So one of the things that I think that doesn't always get said is that our-- and I'm guilty of this as anyone-- but our kids watch what we do. And if we're taking away our kid's phone while we're on our phone, they need to-- I mean, so I think there's the modeling piece. I know, exactly. There's a modeling piece that I think we could all be helped by reducing screens in our lives.

They're attention grabbing devices. There are studies which show if you have your cell phone in your pocket while you're doing a task, your attention is worse. So I think that we could all benefit from that separate from-- I'll let others comment on the book.

Interesting.

Elizabeth Lunbeck: I was a skeptic for many years, but I am completely convinced. I mean, I have some quibbles about some things in the book, but I gave it to my students. They loved it. I now run a class without any devices in the class, and it has changed everything.

Everybody's talking to each other. And the students have said, please take away our devices. So I think--

Al Powell: So protect me from myself.

Elizabeth Lunbeck: Protect me from myself because these devices are meant to be addictive, and they are enormous-- I mean, they're amazing devices. So I worry about the cognitive offloading that's going on when students rely too much. So I would say, yes, get them out of the elementary, junior, and high school classroom.

I also worry about the emotional offloading that they're enabling. But I think the cognitive issues of-- there's been plenty of studies on this. I think they're serious.

Al Powell: So these are key tools that are important in all of our lives, and our kids coming up need to understand how to use them. But we need to somehow figure out how not to let them dominate, and free them up for—

Matthew Nock: That's the theme for me is we have this from Eliza on this new, incredible, increasingly human-like technologies. We want them in our lives. There's benefit to having them, and people can get access to care, and so on, but not that much. So how do we figure out how to integrate with the machines in ways that help us more than harm us? And I think we're still learning-- to some extent, we have a natural experiment happening. But it's, I think, on us, and our students, and our colleagues, and folks in industry to figure this out, and to test, and to experiment, and figure out how we do this.

Al Powell: So we have a question on resources. With the lack of resources to assist our community with these challenges, are there actions that people can take to help those around us? If there's a neighbor who's struggling, or—

Jordan Smoller: Well, I think in general, being willing to connect with people and ask-- checking in with people, people in your life who you see and may be struggling, often people don't want to-- you don't come out and say, I need help. We see this, and Matt can comment on the issue of suicide where it was often thought that you don't want to ask somebody about their suicidal thinking because maybe that would make them--

Worse. --worse. And that's not true. And in fact, a lot of the campaigns, both on the public health side, are directed towards having an awkward conversation, or asking the question, check in with somebody. And I think people underestimate how powerful something simple like that can be.

Karestan Koenen: It's the same with-- we see that with trauma and violent experiences. People don't want to ask people who've experienced a death or something really difficult because they're afraid it'll trigger them, or upset them. But having done this research for so many years and talked to so many people, pretty much across the board, people are relieved if you ask-- if they actually feel like you want to listen to them.

Al Powell: So one of the hard things about being human is embracing the awkward conversations--

Karestan Koenen: Exactly.

Al Powell: --that we all shy away from because it could be helpful, ultimately.

Matthew Nock: It's true. A lot of psychopathology, alcohol use, substance use, suicide, to a large extent, is about escape. It's about escaping feelings I don't want to have, or thoughts I don't want to have. So a lot of the effective interventions teach people to lean in and to experience those feelings.

And this goes to reaching out to other people, as well. It can be awkward. It can be challenging to reach out and say something or talk about something you think the person doesn't want to talk about. The data suggests you should lean in. You should have those conversations.

Karestan Koenen: And they may not even respond the first time, but maybe that you let them know they'll come back later. So even if you don't get the response, and they don't spill it the first time, maybe it still could mean-- they could still remember that. And I'm sure we all have that-- someone who reached out when we were going through a hard time, however we may have reacted.

Everyone else was-- yeah.

Jordan Smoller: And there are, as people probably know, crisis services, or 24/7 988 when people are in a crisis, or the Crisis Text Line that people can reach out to. And that's important to know. But also, this idea of people are often feeling very isolated, lonely, shamed by what they may be feeling. And that kind of connection goes a long way.

Al Powell: So another question on historical perspective. How much of what we're seeing as a rise in loneliness is a recognition of an issue that's been around for a long time, whereas maybe it didn't used to be talked about versus an actual increase?

Elizabeth Lunbeck: It's a really tough question because we always are assuming everything's a brand new problem, and it's worse now than it's ever been, and so on. And there are reports of loneliness and writings about loneliness throughout the 20th century. There's a very powerful historical narrative out there that things have gotten worse and worse, and I think part of that informs the sense of an increasing loneliness crisis.

There are, surveys show, one in three people are very lonely. So we don't have comparable data for earlier. So it's very hard to make a statement, is it getting much worse? Has it always been? I'm not sure.

Karestan Koenen: Are people recognizing it more? Right.

Al Powell: There's always been the cat lady, if you will, or the widower whose wife passed, and he's been—

Karestan Koenen: But what's striking is one in three means there's a lot of people living with other people who say they're lonely, and I think we can mix up living alone and experiencing loneliness, which is another whole interesting, I think, issue.

Elizabeth Lunbeck: And also being alone. So the well-known psychoanalyst and psychiatrist Donald Winnicott wrote an article called The Capacity to be Alone. So there is such a thing as being alone as a kind of an achievement of a mature personality. Just because you're alone doesn't mean you're lonely. So I often use that in teaching students to make a distinction because there's value in spending time alone. It doesn't necessarily mean you're lonely.

Al Powell: So we have a request for some advice. What principles should guide us in deciding when and how to use technology as part of mental health care? Should it be intentional? I'm feeling blue. I'm feeling depressed. Let's see what chat does.

Karestan Koenen: Well, there was one thing I was saying we hadn't-- it's also privacy concerns. So that is another thing we haven't mentioned. So just as a caveat, I don't really have-- just in terms of when we access-- what happens with your data, if you're putting it out there, in terms of your mental health, bringing in other data, accessing your health care data via apps. So there is always-- that's another piece. I think that's a challenge technologically.

Al Powell: So keep that in mind. HIPAA doesn't apply to ChatGPT, right?

Matthew Nock: No, it's big issue. Yeah.

My advice is to always be-- and my advice is to do what I do, which is be guided by science. And there's a lot of apps out there, if you think about should I use this app or that app, what is the evidence that it works? Some things that are really well-intended we have found through science don't help, and some things actually harm.

And as we iterate, we find out, OK, here is the ones that work. Here are the ones that don't. Here are ways of using technology in ways that are helpful. Here are ways that are harmful or ineffective. So I think just as we iterate, there are ways to figure this out.

And I go on pubmed.gov or Google Scholar. And if it's in an area I don't know, which is most areas, someone prescribes a medication for my child, I want to see, has this been tested in randomized controlled trials? There are ways to figure this out using the evidence base that exists.

Karestan Koenen: And if we can make that more accessible to more people, that would be--

Going back to Yelp for mental health.

Al Powell: Do you guys have a sense as to how the news-- I'll throw the news industry in here-- how good a job are they doing on this subject? Do you see the coverage? Is it largely factual, or are they off-base? Because that is an area where people do get some of their news still.

Jordan Smoller: I've been impressed, I think. Especially more recently, I think people are paying a lot of attention to how do you talk about these things, getting the facts right, and so on.

Matthew Nock: Yeah. I think it's on us, as well, as scientists to do more effective science communication and try and get the word out about what the evidence shows.

Karestan Koenen: I have a colleague at the School of Public Health who's been having scientists meet with influencers or creatives. And so that they're providing who are interested in mental health so that the material that they provide on TikTok or other platforms is evidence-based. And she's been very successful with that. I think that could be done more.

She said, come to the School of Public Health. They meet with the faculty, and it's really influenced their content just to make sure that-- they still have complete creative control, but it makes sure that what they're putting out there has evidence.

Al Powell: That's interesting because I think the general perception is that folks who are influencers are just shooting from the hip. But clearly, some of them really care. They want to get it right. They want it right.

Yeah.

So mental health policy focuses on treatment. What are new approaches emerging for prevention, especially with depression and anxiety?

Karestan Koenen: So I'm going to put my public health hat on here and say that there are many policies that we don't label as mental health that influence mental health-- for example, government financial policies. I have another colleague at the School of Public Health who's looked at parents receiving child support payments and showing that when they receive them, mental health visits didn't increase, but mental health of people in the family improved, so from the financial support payments.

So there's just many things, if people are suffering financially-- they don't have enough food. There's food insecurity. Those things will adversely affect those kids, those families' mental health. So when we think of policy, we have to think beyond-- treatment is so important, but we have to think at a broader perspective.

Jordan Smoller: Yeah, I agree. I mean, again, the things that keep coming up are often either social determinants or things that are lifestyle kinds of changes, which is really nice. Because in some ways, those are very modifiable. And we have not really taken on prevention as a field as much as we need to.

And just parenthetically, I worry a little bit about what's going on with the whole funding environment and people getting into science to do all this kind of science-based stuff that we know needs to happen. And we know we need a generation of people to take up those kinds of questions. But I think there are some answers that we have now, that avoiding substances is a big one, as well.

People are very worried about the increase in marijuana use. While alcohol has been going down, marijuana has been going up. And there are known psychiatric complications of that. So yeah.

Matthew Nock: And there's-- just on the same theme, there's effective prevention programs, like suicide prevention programs, that have been tested in schools-- high schools, middle schools-- and shown to be effective. They're not widely used because people fear if we talk about suicide, it will harm kids. 15% of high school students say they've had serious thoughts of suicide in the past year. And we know that asking people about suicide does not harm, and these prevention programs are helpful. We don't use them, by and large, but we do have a lot of training for what to do if there's a school shooter.

The chance of a suicidal kid in school is much higher than a school shooter, so we should be putting prevention programs out there to help keep kids alive and get through this high risk period. So again, I think it's on us to do a better job of communicating this to the public and implementing the prevention programs we have.

Al Powell: So back to your science, follow the science.

Matthew Nock: Follow the science.

Al Powell: The big problem is the one that takes the most lives.

Matthew Nock: Yeah. And it's open. It's transparent, increasingly, science. So I think this is something that we can all engage with in various ways to help try and improve the mental health of our communities.

Elizabeth Lunbeck: And Jordan's point, to fund the science.

Al Powell: And fund the science.

Fund the science. And we'll see how that turns out in the coming weeks and months. So we're just about out of time. I'd like to thank our panelists here for what was a lively discussion. I'd like to invite the listeners to tune in the next time to From the Studio.