Thank you, Jim, for that warm introduction.  Jim has been a good friend and a tireless advocate over the years.  We in Rhode Island are lucky to have him. I must also thank Dr. Hyman for the invitation to join you today.

I also want to express my appreciation to NIMH for pulling together this gathering Thanks to all of you, we know so much more about depression and other mental illnesses than we did even a short time ago.  We can see physical changes in the brain previously hidden.  There are new more effective drugs with fewer side effects.  Genetic research gives us new insights into depression's causes.

The advances in our understanding have improved the lives of so many.  And yet many unanswered questions remain.

I can think of no better way to move towards those answers than by putting the country's leading experts in a room together.  I hope this conference allows you to share information and learn from each other’s knowledge.

I hope it is energizing and inspiring and catalyzing.  A meeting like this allows us to take stock, reflect on our successes -- and failure - and draw strength from each other to push onward in our common pursuit. You certainly ought to inspire each other, because the work you do is incredibly important. Our work to bring more effective treatments to more people is, in the finest American tradition, an effort to promote opportunity.  It is extending the American dream to those who have had difficulty seeing its promise.

The American story is one of ever-expanding access to the opportunities afforded by this nation.  

At its founding, the United States inherited a social structure in which great barriers to the inner circle of opportunity existed.  It was a vast improvement over European societies, to be sure, but for slaves, women, displaced native populations, indentured servants, and other powerless groups, the words of the Declaration of Independence and Constitution rang hollow.  The American ideals are so powerful, however, that with every successive generation, barriers to America's promise have fallen.  Over time, we've seen improved access to the economic and political mainstream by the landless, various waves of immigrants, women, African Americans, the disabled.

There can be no question that we have a long way to go until America’s opportunities are available to all on a truly egalitarian basis.  But there can likewise be no question that our history has been a steady march towards that ideal.

As we develop more effective treatments, learn how to prevent the onset of mental illness, and expand access to both preventive services and treatment, we similarly open doors.  We write another chapter in our country's most stirring story and we widen the inner circle yet again.

By focusing on the scope of depression's impact, this conference contributes to that effort.  Depression is, of course, a frequently debilitating disease that warrants our attention in its own right.  But what makes it so insidious is the breadth of its deleterious influences.

This conference is exploring the medical fallout of depression.  Research has demonstrated, for example, that depression is a significant risk factor for heart disease.  In one study of people with no heart disease, patients with a history of depression were four times more likely than others to suffer a heart attack over a fourteen-year period.  You are also looking at the impact of depression on other diseases such as Parkinson's, diabetes, and cancer, and vice-versa.

Just as depression can generate other negative medical effects, the social fallout of depression is immense.

According to the Global Burden of Disease study conducted by the World Health Organization, the World Bank, and Harvard, depression is the leading cause of disability worldwide.  Only heart disease has a greater negative impact on the number of disability-free years lived by residents of developed countries.

The Rand Corporation estimated that depression cost the U.S. between 30 and44 billion dollars in 1990.  That total includes a 12 billion dollar price tag for lost workdays resulting from depression and another 11 billion dollars in the costs of depression-induced losses in productivity.

The cost is also borne in a currency far more valuable than dollars. Suicide is the eighth leading cause of death in the United States, and the third most common cause of death among 15 to 24-year-olds.  White men aged 85 and older commit suicide at a rate of 6 times the national average.

But we do not need statistics to understand the impact.  We see daily the toll taken by depression and other mental illnesses.

We see it in our elderly friends, parents, and grandparents, beset by grief and feelings of worthlessness, inconsolable.

We see it in our daughters and sisters who literally starve themselves in subservience to eating disorders.

We see it in so many of our closest friends and family members who have trouble holding a job or getting through school or maintaining relationships.

We don't need to see research to know the devastation that mental illness can wreak - it's all around us, in the faces of people we love. This conference is a recognition by the leading experts in the country that mental illness is indistinguishable from physical illness, that mental health is integral to total health.

Just as the medical community is expanding its understanding of the co-occurrence of depression and other illnesses, so must our larger community pay greater attention to the co-occurrence of mental illness and academic failure, job loss, crime, and other social phenomena.

It is these social consequences of mental illness that make our efforts so vital.  NIMH and all of you here are doing more than solving medical problems; you are opening doors that once were closed.  You are helping write the next chapter in a history of opportunity by fundamentally changing the prognosis for those with mental illness. 

Investments in research pay dividends for real people.  Now, more than 80 percent of those who seek treatment for clinical depression show improvement. 

And NIMH continues to build on that success, striving to tie together basic and applied research.  I applaud this emphasis on translational research. By building connections from the lab to clinical settings and from clinical settings to the lab, you are maximizing the impact of your research on the lives of those living with mental illness.

And NIMH continues to build on that success, striving to tie together basic and applied research.  I applaud this emphasis on translational research. By building connections from the lab to clinical settings and from clinical settings to the lab, you are maximizing the impact of your research on the lives of those living with mental illness.

Expanding access to mental healthcare is a two-pronged effort.  Like those who have written earlier chapters of our nation's history, we face the challenge of changing institutions and institutional thinking.  We must modernize the infrastructure of the mental health system and fight the stigma that so stubbornly clings to mental illness.

Erasing stigma is the leverage point in our efforts to improve mental health. Until we cut down the stigma attached to mental health, our other efforts will fall short.  The stigma is so pervasive that it shapes our entire healthcare system, from start to finish.

The implications of this mindset are profound.  Look at an area near and dear to those associated with NIMH, research.

It seemed that nearly every page of the Surgeon General's report identified specific areas in which further mental health research was needed.  He specifically singled out an urgent need for research into mental health promotion and illness prevention.  I'm sure that everyone in this room could create a list of vital research needs.

But notwithstanding the gaps in the research base, less than five and a half of every hundred dollars spent this year on research is going to NIMH. And that figure has decreased in all but one of the last seven years.

From one point of view, the funding for NIMH seems pretty reasonable. Its budget has increased at roughly the same rate as NIH's.  It's one of the better-funded institutes within NIH.

But I think that if the disease burden of mental illness is second only to heart disease, and if it touches one in every five Americans, we ought to be spending more than five percent of our research budget on mental illness.  

According to the World Health Organization study, mental illnesses - and that does not include alcohol or drug use - mental illnesses are responsible for fifteen-point-four percent of lost years of healthy life.  Cancers are responsible for fifteen percent.

The disease burdens of mental illnesses and cancers are about the same-mental illness is actually a bit higher - yet the National Cancer Institute gets almost three and a half times the funding of NIMH.

I'm not advocating that we take funding away from cancer research to support mental health research.  My point is that the perception that mental health is an add-on to real health keeps research funding levels significantly disproportionate to the impact of mental illness on our country.

Another effect of the notion that mental health is not real health is that primary care providers are not given the training necessary to reliably diagnose and treat mental illness.  A recent survey reveals that over three-quarters of patients treated for depression said their symptoms have not been completely controlled during the last two months though they have been on the same antidepressant for an average of three to five years.  It takes, on average, ten years from the onset of symptoms of bipolar disorder to diagnosis.

This is not to blame primary care providers.  The blame falls on a system that expects primary care providers to treat complex, serious diseases.

And because mental health is not real health, we also have reimbursement policies that undervalue mental health treatment.  Why are co-payments higher for outpatient treatment, or hospitalization benefits more strictly limited for mental illnesses than for other diseases?

No other category of illnesses is treated that way.  What is the implication? That mental healthcare is somewhere between cosmetic surgery or other voluntary procedures and the "real" health care that insurance policies are intended to cover.

And if the supply side of the treatment equation is shaped by this archaic conception of mental health and the resulting stigma, the demand side is even worse.

According to the Surgeon General, nearly two-thirds of those with mental illness do not seek treatment.  A major reason is that people are embarrassed to admit that they have mental health problems.

Imagine two out of every three people suffering from some other disease not seeking treatment.

It's estimated that 60 percent of students who visit a school nurse for physical ailments end up discussing mental health problems.  If those students are so reluctant to address their mental health concerns head-on, how many students do not seek treatment at all?

Because mental illness is seen as separate from real medical problems, there is a persistent belief that mental illness is within an individual's control.

Depression and other mental illnesses are not generally perceived as external forces acting on an individual.  They are not appreciated as serious diseases.  Depressed?  Snap out of it!  

And if you should be able to snap out of it and don't, well then that is a sign of your weakness.  We don't cast moral judgment on asthmatics or diabetics or others suffering from chronic diseases.  Only mental illness is the fault of its victim.

This attitude may have been understandable if unfortunate in an earlier era. But given what we know about the physiological causes of depression and other mental illnesses, it is inexcusable today.  If the functioning of my brain is such that I have a stroke, I get sympathy.  If my brain instead happens to produce depression, I get blamed for the symptoms.

If our goal is to bring new, ever more effective treatments to those in need, we must tackle this stigma.  Until we overcome this perception that mental illness is a character flaw, rather than a disease, the largest obstacle to treatment will remain unmoved.

For this reason, while I am working on the health care subcommittee of Appropriations to increase funding in genetic and behavioral health research as well as on legislation to increase and improve the delivery of mental health services, I think the single most important task before me, and all of us, is shining light on issues of mental health long kept out of view.

For too long, mental illness has not been discussed. The public discourse on the subject has been limited to whispers.

It is imperative that we talk about mental health in full voices, without embarrassment or apology.  I want to put mental health on the national agenda.  We should inject mental health into debates about education, overall health care, and the criminal justice system, to name a few.