This year, he assumed a new role to help Gov. Gavin Newsom revamp mental health care in the state. Newsom called Insel his “,” though his position is unpaid and Insel says it grants him “no authority.” Even so, he is zigzagging across California this summer, visiting mental health facilities to try to understand what works and what doesn’t.

Insel’s meandering career path began early. A precocious student, he enrolled in a joint B.A.-M.D. program at Boston University at age 15 and then took a one-year hiatus to volunteer in clinics across Asia. He returned to finish his medical degree and later completed a three-year psychiatry residency at the University of California-San Francisco.

As a young scientist at the National Institute of Mental Health in the 1980s, Insel researched the effects of antidepressants, then shifted gears to study the in the prairie vole, a rodent known for monogamous behavior.

His groundbreaking research that the vole’s devotion to a single mate was attributable to higher levels of a protein in its brain. That work — along with earlier research on anxiety in monkeys — led to a job running the Yerkes National Primate Research Center in Atlanta starting in 1994. He returned to NIMH in 2002 as its director and headed the institute, the world’s largest funder of mental health research, for the next 13 years.

In 2015, Insel left NIMH to lead mental health initiatives at Verily, Google’s life sciences research subsidiary. He jumped ship after a year and a half to join a startup, Mindstrong Health, which hopes to prove that the way people use their smartphones can reveal the state of their mental health — and provide opportunities to intervene. Insel also serves as board chairman of the Steinberg Institute, a Sacramento-based nonprofit focused on California mental health policy.

In May, he took a temporary leave from Mindstrong to work intensively, at Newsom’s behest, on a mental health plan for the state. He intends to return to the company early next year and continue advising the governor for “as long as I can be useful.”

California Healthline joined Insel on Aug. 19 as he toured Oakland’s Trust Clinic, a medical and mental health center serving the city’s homeless population. We sat down with him for an interview afterward. His comments have been edited for space and clarity.

Q: How would you describe the state of mental health in California and in the U.S.?

California has all the issues every other state has — incarceration, homelessness, fragmentation. More than half of people with mental illness are not getting care. There is a very shallow workforce, particularly for kids. We don’t have inpatient beds where we need them.

I’ve spent 40 years working in this field. We have seen vast improvement in those 40 years in infectious diseases, cardiovascular care, many areas of medicine, but not behavioral health. Suicides are up about 33% since the turn of the century. Overdose deaths are skyrocketing. People with serious mental illness die about 23 years early — and we’re not closing that gap. We’ve got to come up with better solutions now.

Q: What insights are you gaining as you visit programs around the state?

People managing these programs are heroic in what they’re able to do with limited resources and tremendous demands. We have 58 mental health systems because we have 58 counties, and we have a separate system for mild to moderate mental illness. It’s very fragmented — including between mental health and substance use. One family might interact with four different providers to get behavioral health care. That’s not the system one would design if you’re starting with the patient.

Q: How should the system be designed?

The system now is crisis-driven. The biggest transformation will come when we can identify problems and intervene earlier. That’s when we get the best outcomes in diabetes, heart disease, cancer. It’s equally true in behavioral health. We have to manage crisis better, keep people out of the criminal justice system, provide more continuity of care. But we also have to move upstream and capture people much earlier in their journey. This will require building infrastructure we don’t have right now: crisis residential beds, sub-acute beds, places for people to live.

Q: So how do we bring about the needed changes?

California has one advantage few states enjoy. The Mental Health Services Act (MHSA) will provide $2.4 billion this year, including for early intervention, prevention and innovation. We also have [other] funds. Every county is using those funds in the way it sees fit.

The time has come to ask: How can we reduce suicide, overdose deaths and re-hospitalization in California? One approach would be to set goals for these, i.e., reduce suicide by X% in Y years. Housing and incarceration have gotten worse over time. Should the state make a pledge to its citizens to do better in those areas?

Q: Who would ensure such a pledge is honored?

Counties are still ground zero for all this. They’re our connection to schools and jails, and places where the mental health crisis is playing out. The question is, can the state do more to help them succeed? One thing I’ve heard from every county is that the burden for documentation means that 35% to 40% of the time is taken up with paperwork, not providing services. Can we set them loose to do what they want to do?

Q: Can technology play a role in improving mental health?

As much as one might hope there’d be an app for that — it’s really complicated. In the months I’ve focused on creating a mental health plan for California, technology is barely in the conversation. Having said that, I do think in the future using digital tools to connect people to care will be transformative.

Q: The recent mass shootings in El Paso and Dayton, like numerous others before them, were perpetrated by angry, alienated young men. What does this say about our culture and the American psyche?

It’s a complicated question. There is an element of untreated mental illness that leads to high risk of violence. That violence is usually self-directed in the form of suicide; occasionally, it’s other-directed. We did better, oddly enough, when I started in the field than we’re doing today in providing more comprehensive, continuous care. I think we are in a crisis, but it’s a crisis of care. So whether the mass shootings are a reflection of that or not — maybe to some extent, but they’re a small part of a much bigger issue. We are failing to provide care to people with brain disorders. We need to do better.

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Lee Frierson, an unpaid volunteer, introduces himself as he and his team leader, Charlie Jones, unpack chips, soda, batteries and shampoo that they will hand out as prizes.

“I’m Lee with Reach Out,” Frierson says. “I’m a peer. I suffer from depression. It helps me to help you guys.”

“And I’m Charlie the angel,” Jones says. “We go to board-and-cares and psychiatric and wellness facilities to inspire hope and model recovery.”

A few rounds into the game, Frierson calls B-5, and a dark-haired man shouts, “Bingo!”

“Winner, winner, chicken dinner!” Frierson calls back, prompting chuckles.

What unfolds in this room is not exactly therapy, but it is something that mental health advocates and suggest can be healing in its own right: people who have struggled with mental illness helping others who are experiencing similar struggles. Frierson and Jones are former mental health patients who now work with the Reach Out program, part of the nonprofit , which provides what is called peer support.

The value of peer support is recognized by Medicaid, the health insurance program for people with low incomes, and it funds such services. That money is available for certified peer-support workers in states that have a formal certification process.

California does not, and that means it is “leaving money on the table,” said Keris Myrick, chief of peer services at the Los Angeles County Department of Mental Health. South Dakota is the only other state with no peer certification program.

But a bill pending in Sacramento, , would direct the State Department of Health Care Services to create a process for certifying peer support workers and establish a set of core aptitudes and ethics guidelines for the job. The legislation passed the state Senate unanimously in May and will move to the Assembly Health Committee on Tuesday.

More than 6,000 peer support specialists already work in wellness programs, hospitals and clinics across California, according to SB-10’s sponsor, Sen. Jim Beall (D-San Jose). They help mental health patients navigate bureaucracies, find housing or locate services.

“They’re sharing their experiences: ‘Been there, done that, now I’m going to help another person,’” said Myrick, who has been diagnosed with schizoaffective disorder, was hospitalized several times and spent 10 years running a peer support program in Los Angeles.

Last year, the legislature unanimously passed a bill to certify peer support workers, but then-Gov. Jerry Brown it, saying it was costly and unnecessary.

Legislative analysts estimate the state would spend hundreds of thousands of dollars to set up a certification process and millions more a year to implement it. Advocates say the new federal money would help offset those costs. And, they say, the legislation would cement the bona fides of peer mentoring as an occupation.

Gov. Gavin Newsom has not declared his position on the current bill, but he has said that addressing the state’s mental health crisis is a top priority for his administration. During , he endorsed “ for nurse practitioners and peer providers.”

Dr. Thomas Insel, a former director of the National Institute of Mental Health whom Newsom named in May as a , told California Healthline he supports the peer certification bill.

“For many people, having a connection to someone else who’s had this experience proves vital,” Insel said. “There may be nothing more healing than giving people an opportunity to help others.”

Peer programs in the 1970s opposing coercive psychiatric treatment, led by people who’d been treated against their will and felt they would receive better care from those who personally identified with their experiences.

Many peer-run groups already offer training in peer support techniques to current or former mental health clients. The Alameda County Network of Mental Health Clients runs a training program called , which graduates 18 to 20 people a year. Fifteen of the network’s 25 staff members graduated from that program.

Among them is Charlie Jones, the program manager for Reach Out who coordinates the teams of peers that visit residential programs. Jones, 43, experienced nervous breakdowns in her 20s and 30s and was hospitalized several times. She eventually enrolled in college and is completing a degree in human development at California State University-East Bay.

Jones was a mentor to Frierson before he volunteered for her team. They met several months ago when Jones and her colleagues organized a bingo game at a board-and-care home where Frierson was recovering from severe depression.

“We talked and I listened to people who’d been in a similar situation,” Frierson said. “It really pumped me up.”

Now Frierson plans to enroll in BestNow! and become a peer specialist. He said he hopes he’ll eventually be certified by the state of California.

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En ese vecindario de bajos ingresos, predominantemente latino, es bastante difícil para un niño evitar el azúcar. El año pasado, los médicos del , una clínica comunitaria sin fines de lucro a siete cuadras de distancia, se alarmaron por el aumento de peso de Adrián Mejía, el hijo de Díaz. Lo convencieron para que participara de un dirigido por la Universidad del Sur de California y el Hospital Infantil de Los Ángeles (CHLA) que elimina el azúcar de la dieta de los participantes en un esfuerzo por reducir la tasa de obesidad y diabetes en niños.

Y también apunta a una tercera condición de la que pocos han oído hablar: enfermedad del hígado graso.

Vinculada tanto a la genética como a las dietas altas en azúcar y grasa, “la enfermedad del hígado graso está afectando a la comunidad latina como un tsunami silencioso, que impacta especialmente a los niños”, dijo el doctor Rohit Kohli, jefe de gastroenterología, hepatología y nutrición de CHLA.

Investigaciones recientes muestran que aproximadamente 1 de cada 4 personas en los Estados Unidos sufre la enfermedad del hígado graso. Pero entre los latinos, especialmente de ascendencia mexicana y centroamericana, la tasa es significativamente más alta. Un en Dallas encontró que el 45% de los latinos tenía hígado graso.

La enfermedad, que se diagnostica cuando más del 5% del peso del hígado es grasa, no causa problemas graves en la mayoría de las personas. Pero puede progresar a una afección más grave llamada , que está relacionada con la cirrosis, el cáncer de hígado y la insuficiencia hepática. Esta forma progresiva de la enfermedad del hígado graso es la causa de más rápido crecimiento de los .

El año pasado, el estudio de USC-CHLA, que lidera Michael Goran, director del Programa de Diabetes y Obesidad de CHLA, hizo un : el azúcar de las bebidas endulzadas puede pasar de la leche materna a los bebés, lo que podría predisponerlos a la obesidad. Y a sufrir de hígado graso.

El programa, llamado HEROES (Healthy Eating Through Reduction of Excess Sugar), está diseñado para ayudar a los niños como Adrián, quien solía tomar cuatro o más bebidas azucaradas al día, a desterrar hábitos poco saludables que pueden provocar hígado graso y otras enfermedades.

La enfermedad del hígado graso está ganando más atención en la comunidad médica a medida que los legisladores aumentan la presión para desalentar el consumo de bebidas llenas de azúcar. Representantes en Sacramento, California, están considerando propuestas para imponer un impuesto estatal a las gaseosas, poner etiquetas de advertencia en las bebidas azucaradas y prohibir que las empresas que producen estas bebidas ofrezcan cupones de descuento para comprarlas a menos precio.

“Apoyo los impuestos sobre el azúcar y las etiquetas de advertencia como una forma de desalentar el consumo, pero no creo que eso solo logre resultados”, dijo Goran. “También necesitamos estrategias de salud pública que limiten la comercialización de bebidas azucaradas, bocadillos y cereales para bebés y niños”.

William Dermody, vocero de la American Beverage Association dijo: “Entendemos que tenemos un papel que desempeñar para ayudar a los estadounidenses a controlar el consumo de azúcares agregadas, por lo que estamos creando más bebidas con menos o nada de azúcar”.

En 2016, 45 muertes en el condado de Los Ángeles se atribuyeron a la enfermedad del hígado graso. Pero eso es una “gran subestimación”, porque cuando las personas con la enfermedad mueren, a menudo tienen cirrosis y eso es lo que aparece en el certificado de defunción, dijo el doctor Paul Simon, director científico del Departamento de Salud Pública del condado.

Simon dijo que, aun así, fue sorprendente que el 53% de las muertes en 2016 atribuidas a la enfermedad del hígado graso fueran entre latinos, casi el doble de la proporción del total de muertes en el condado.

Investigadores consideran que la enfermedad del hígado graso es una manifestación de algo llamado síndrome metabólico, un conjunto de afecciones que incluyen exceso de grasa abdominal y presión arterial elevada, azúcar en la sangre y colesterol, que pueden aumentar el riesgo de enfermedad cardíaca, accidente cerebrovascular y diabetes.

Hasta 2006, pocos médicos sabían que los niños podían desarrollar la enfermedad del hígado graso. Ese año, el doctor Jeffrey Schwimmer, profesor de pediatría en la Universidad de California-San Diego, , de 2 a 19 años, quienes habían muerto en accidentes automovilísticos o por otras causas, y descubrió que 13% tenía enfermedad del hígado graso. Entre los niños obesos, el 38% lo padecía.

Después que se publicó el estudio de Schwimmer, Goran comenzó a usar resonancias magnéticas para diagnosticar el hígado graso en niños vivos.

Un realizado en 2008 por otro grupo de investigadores impulsó a Goran más allá. Mostró que una variante de un gen llamado PNPLA3 aumentaba significativamente el riesgo de la enfermedad. Según Goran, alrededor de la mitad de los latinos tienen una copia de ese gen de alto riesgo, y una cuarta parte tiene dos copias.

Goran comenzó , que mostró que, entre los niños de tan solo 8 años, los que tenían dos copias del gen de riesgo y consumían altas cantidades de azúcar tenían tres veces más grasa en sus hígados que los niños sin copia del gen. Ahora, en el estudio de USC-CHLA, se está evaluando si la reducción en el consumo de azúcar disminuye el riesgo de hígado graso en niños que tienen la variante del gen PNPLA3.

Al comienzo del estudio, se examina a los niños para ver si tienen el gen PNPLA3, se usa una MRI para medir su grasa hepática y se cataloga su consumo de azúcar. Un dietista del equipo educa a la familia sobre el impacto del azúcar. Luego, después de cuatro meses, vuelven a medir la grasa del hígado para evaluar el impacto de la intervención. Goran espera tener resultados del estudio en aproximadamente un año.

Más recientemente, Goran ha estado investigando la transmisión de azúcar de las madres a sus bebés. El año pasado demostró que en madres lactantes que bebían bebidas endulzadas con jarabe de maíz con alto contenido de fructosa, el edulcorante principal en formulaciones estándar de , y otras sodas, el nivel de fructosa en la leche materna aumentaba y se mantenía elevado durante varias horas, asegurándose que el bebé lo ingiera.

Esta exposición temprana al azúcar podría estar contribuyendo a la obesidad, la diabetes y el hígado graso, según que demostraron que la fructosa puede mejorar la capacidad de almacenamiento de grasa de las células, explicó Goran.

En barrios como el sur de Los Ángeles, donde viven Saira Díaz y Adrián Mejía, la falta de supermercados y productos frescos hace que sea más difícil comer sano. “El acceso a opciones de alimentos poco saludables, que generalmente son más baratos, es muy alto en esta ciudad”, dijo a Kaiser Health News Derek Steele, director de programas de equidad en salud en el Social Justice Learning Institute, en Inglewood, California.

El instituto comenzó con mercados de granjeros, ayudó a convertir dos tiendas en mercados con opciones de alimentos más saludables y creó 109 huertas comunitarias en terrenos públicos y privados en el sur de Los Ángeles y el vecino Inglewood, que cuenta con 125 tiendas de licores y pequeños comercios, y 150 establecimientos de comida rápida.

En Torrance Memorial Medical Center, a 10 millas de distancia, el doctor Karl Fukunaga, gastroenterólogo con Digestive Care Consultants, dijo que él y sus colegas ven a tantos pacientes con enfermedad del hígado graso que planean comenzar con una clínica específicamente para abordar el problema. Fukunaga insta a sus pacientes a evitar el azúcar y reducir los carbohidratos.

Adrián Mejía y su madre recibieron consejos similares de un nutricionista en el programa HEROES. Adrián dejó de tomar bebidas azucaradas, y su grasa hepática se redujo en un 43%. Hace dos meses, comenzó a jugar en un equipo de fútbol.

“Antes, pesaba mucho y era difícil correr”, dijo. “Si continuara al ritmo al que iba, probablemente más tarde en mi vida sería como mi abuela [diabética]. No quiero que pase eso”.

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In that low-income, predominantly Latino neighborhood, it’s pretty hard for a kid to avoid sugar. Last year, doctors at , a nonprofit community clinic seven blocks away, became alarmed by the rising weight of Diaz’s son, Adrian Mejia. They persuaded him to join an run by the University of Southern California and Children’s Hospital Los Angeles (CHLA) that weans participants off sugar in an effort to reduce the rate of obesity and diabetes among children.

It also targets a third condition fewer people have heard of: fatty liver disease.

Linked both to genetics and diets high in sugar and fat, “fatty liver disease is ripping through the Latino community like a silent tsunami and especially affecting children,” said Dr. Rohit Kohli, chief of gastroenterology, hepatology and nutrition at CHLA.

Recent research shows about 1 in 4 people in the U.S. have fatty liver disease. But among Latinos, especially of Mexican and Central American descent, the rate is significantly higher. in Dallas found that 45% of Latinos had fatty livers.

The illness, diagnosed when more than 5% of the liver’s weight is fat, does not cause serious problems in most people. But it can progress to a more severe condition called nonalcoholic steatohepatitis, or NASH, which is linked to . This progressive form of fatty liver disease is the .

The USC-CHLA study is led by Michael Goran, director of the Diabetes and Obesity Program at CHLA, who last year made : Sugar from sweetened beverages can be passed in breast milk from mothers to their babies, potentially predisposing infants to obesity and fatty livers.

Called HEROES, for Healthy Eating Through Reduction of Excess Sugar, his program is designed to help children like Adrian, who used to drink four or more sugary drinks a day, shed unhealthy habits that can lead to fatty liver and other diseases.

Fatty liver disease is gaining more attention in the medical community as lawmakers ratchet up pressure to discourage the consumption of sugar-laden drinks. Legislators in Sacramento are mulling proposals to impose a statewide soda tax, put warning labels on sugary drinks and bar beverage companies from offering discount coupons on sweetened drinks.

“I support sugar taxes and warning labels as a way to discourage consumption, but I don’t think that alone will do the trick,” Goran said. “We also need public health strategies that limit marketing of sugary beverages, snacks and cereals to infants and children.”

William Dermody, a spokesman for the American Beverage Association said: “We understand that we have a role to play in helping Americans manage consumption of added sugars, which is why we are creating more drinks with less or no sugar.”

In 2016, 45 deaths in Los Angeles County were attributed to fatty liver disease. But that’s a “gross underestimate,” because by the time people with the illness die, they often have cirrhosis, and that’s what appears on the death certificate, said Dr. Paul Simon, chief science officer at the L.A. County Department of Public Health.

Still, Simon said, it was striking that 53% of the 2016 deaths attributed to fatty liver disease were among Latinos — nearly double their proportion of total deaths in the county.

Medical researchers consider fatty liver disease a manifestation of something called metabolic syndrome — a cluster of conditions that include excess belly fat and elevated blood pressure, blood sugar and cholesterol that can increase the risk of heart disease, stroke and diabetes.

Until 2006, few doctors knew that children could get fatty liver disease. That year Dr. Jeffrey Schwimmer, a professor of pediatrics at the University of California-San Diego, of 742 children and teenagers, ages 2 to 19, who had died in car crashes or from other causes, and he found that 13% of them had fatty liver disease. Among obese kids, 38% had fatty livers.

After Schwimmer’s study was released, Goran began using MRIs to diagnose fatty liver in living children.

A 2008 by another group of researchers nudged Goran further. It showed that a variant of a gene called PNPLA3 significantly increased the risk of the disease. About half of Latinos have one copy of that high-risk gene, and a quarter have two copies, according to Goran.

He began a new study, which that among children as young as 8, those who had two copies of the risky gene and consumed high amounts of sugar had three times as much fat in their livers as kids with no copy of the gene. Now, in the USC-CHLA study, he is testing whether reduced consumption of sugar decreases the fatty liver risk in children who have the PNPLA3 gene variant.

At the start of the study, he tests kids to see if they have the PNPLA3 gene, uses an MRI to measure their liver fat and catalogs their sugar intake. A dietitian on his team educates the family about the impact of sugar. Then, after four months, they measure liver fat again to assess the impact of the intervention. Goran expects to have results from the study in about a year.

More recently, Goran has been investigating the transmission of sugar from mothers to their babies. He that in nursing mothers who drank beverages sweetened with high-fructose corn syrup — the primary sweetener in standard formulations of , and other sodas — the fructose level in their breast milk rose and stayed elevated for several hours, ensuring that the baby ingested it.

This early exposure to sugar could be contributing to obesity, diabetes and fatty livers, based on that showed fructose can enhance the fat storage capacity of cells, Goran said.

In neighborhoods like South Los Angeles, where Saira Diaz and Adrian Mejia live, a lack of full-service markets and fresh produce makes it harder to eat healthily. “Access to unhealthy food options — which are usually cheaper — is very high in this city,” Derek Steele, director of health equity programs at the Social Justice Learning Institute in Inglewood, Calif., told Kaiser Health News.

The institute has started farmers markets, helped convert two corner stores into markets with healthier food options and created 109 community gardens on public and private lands in South L.A. and neighboring Inglewood, which has 125 liquor and convenience stores and 150 fast-food outlets.

At Torrance Memorial Medical Center, 10 miles down the road, Dr. Karl Fukunaga, a gastroenterologist with Digestive Care Consultants, said he and his colleagues are seeing so many patients with fatty liver disease that they plan to start a clinic to address it. He urges his patients to avoid sugar and cut down on carbohydrates.

Adrian Mejia and his mother received similar advice from a dietitian in the HEROES program. Adrian gave up sugary beverages, and his liver fat dropped 43%. Two months ago, he joined a soccer league.

“Before, I weighed a lot and it was hard to run,” he said. “If I kept going at the pace I was going, probably later in my life I would be like my [diabetic] grandma. I don’t want that to happen.”

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Born to a Jewish family in Budapest at the time of the Nazi occupation, he and his parents migrated to Canada, where he earned his medical degree at the University of British Columbia. Maté, whose personal experience informs his work, is known for tracing substance abuse problems to trauma that often starts in childhood and spans generations.

His work has been acclaimed, but a suggested that his theories are reductionist and unsupported by data — a contention Maté disputes.

Amid the severe opioid epidemic in the U.S., Maté recently visited Sacramento, where he conducted workshops with addiction specialists and families affected by addiction. California Healthline contributor Rob Waters caught up with him there. The following interview was condensed and edited for clarity.

Q: A big part of your book “In the Realm of Hungry Ghosts” is about how you came to see that childhood trauma and pain lie at the root of addiction. Tell me about your insights.

Downtown Eastside is North America’s most concentrated area of drug use. In 12 years, I worked with hundreds of female patients, and every one had been sexually abused as a child. Men were physically, sexually and emotionally abused, suffered neglect, were in foster care.

Thirty percent of people there are native Indians, what we call First Nations people. For generations, the government abducted their children and sent them to residential schools. Parents were barred from seeing kids. Kids were physically and sexually abused by teachers and priests. Tens of thousands died. Because of multigenerational trauma, native communities have high rates of sexual abuse, violence, addiction and suicide. It’s the most addicted population in Canada.

All addictions — alcohol or drugs, sex addiction or internet addiction, gambling or shopping — are attempts to regulate our internal emotional states because we’re not comfortable, and the discomfort originates in childhood. For me, there’s no distinction except in degree between one addiction and another: same brain circuits, same emotional dynamics, same pain and same behaviors of furtiveness, denial and lying.

Q: You were born into a Jewish family in Budapest during the Holocaust. How did that affect your life?

I was born in 1944, and two months later the Germans came in. Hungary then had the only population of Jews in Eastern Europe that hadn’t been annihilated. Now it was our turn. My mother had a stressed pregnancy. My father’s away in forced labor; she doesn’t know if he’s dead or alive. When I’m 5 months of age, my maternal grandparents are sent to Auschwitz and gassed to death. My mother is 24, terrified and depressed. In October, they start killing Jews in Budapest, taking them to the Danube and shooting them.

When I’m 11 months, she gives me to a total stranger. She said: “Please take this baby out of here because I can’t keep him alive.” I didn’t see her for six weeks. In a child’s mind, that’s abandonment. I got the template for addiction: a lot of emotional pain, which I suppressed.

Q: You write about your own addictions — being a workaholic and binge shopper of classical music, once spending $8,000 in a week on CDs.

I was not addicted to substances but I might as well have been. I couldn’t stop myself. I lied to my wife. I lied to my kids. It doesn’t matter which addiction you’re looking at; it’s the same dynamics.

Q: Last year in the U.S., an estimated of drug overdoses, most from opioids. The U.S. penalizes drug use harshly and has the largest prison population in the world — 2.3 million people, almost . Meanwhile, 90 percent of people with substance use disorders in the U.S. are . What’s your take on this approach?

The more pain you cause people, the more you shame and isolate them, the worse they’ll feel about themselves. The more suffering you impose, the more you strengthen their need to escape. If you wanted to design a system to maintain drug use and enhance the profits of the illegal drug trade, I would design the system you have.

Q: Let’s talk about the science. How does trauma in the early years of life affect brain development and predisposition to addiction?

Studies show that early stress affects both the nerve cells in the brain and the immune systems of mice and humans and makes them more susceptible to cocaine as adults. If you look at brain circuits implicated in impulse regulation or stress regulation or emotional self-regulation, all are impaired in addicts.

Q: Why do you think the opioid epidemic exploded in the way it has in recent years?

On top of the childhood trauma and the profound social and economic dislocation so many people experience, most physicians are completely uninformed about trauma and don’t understand how to address chronic pain or treat addiction. Hence they have a propensity to prescribe opiates all too quickly without looking at root causes or alternatives. Most people introduced to opiates in recent years started on medical prescriptions. When these are stopped, they turn to illicit substances. All this is greatly exacerbated by pharmaceutical companies’ well-documented drive to induce doctors to prescribe.

Q: Critics like psychologist and addiction specialist Stanton Peele say you’re proposing a reductionist vision in which abuse history and biochemical changes to the brain inevitably lead to substance abuse.

Peele totally misconstrues my argument. Nobody’s saying that every traumatized person becomes addicted. I’m saying that every addicted person was traumatized. There are other outcomes of trauma including cancer, autoimmune disease, mental illness — addiction is only one of them.

Q: You write with compassion about the people you worked with. But you also write about them as broken people who rarely seem to recover. What good are you doing?

If somebody had cancer and pain and you couldn’t cure the cancer, what would you do? Would you say, “I’m not going to help you any more”? Or would you try to ameliorate their suffering? The essence of harm reduction is you reduce the harm. You don’t impose abstinence. If they choose that at some point, I provide whatever support they need.

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De la misma manera, después del tiroteo en una escuela de Parkland, Florida, en febrero, en el que murieron 17 personas entre estudiantes y personal, Trump tuiteó que había “muchos indicios de que el que disparó estaba mentalmente perturbado”.

Sin embargo, expertos en salud pública y salud mental argumentan que culpar a las personas con enfermedades mentales de la violencia es injusto e impreciso, y señalan que a lo que se debería mirar es a la laxitud de las leyes sobre armas de fuego.

“La mayor parte de los actos violentos no los cometen personas mentalmente enfermas”, enfatizó la doctora Renée Binder, profesora de psiquiatría de la Universidad de California en San Francisco y ex presidenta de la American Psychiatric Association. “Aunque nos hiciéramos cargo de todos los que sufren algún tipo de trastorno mental y los encerráramos y los medicáramos, apenas comenzaríamos a indagar en el problema de la violencia”.

En los debates que les siguen a estas masacres, las opiniones son blancas o negras, pero la investigación muestra que la verdad tiene zonas grises.

Tanto los “defensores de eliminar el estigma”, que insisten en que la enfermedad mental no tiene relación con la violencia, y los “propagadores del temor”, que afirman que “los enfermos mentales son una amenaza peligrosa y deben ser encerrados”, están equivocados, dijo Jeffrey Swanson, profesor de psiquiatría de la Universidad de Duke, quien ha estudiado los patrones de violencia en las principales ciudades de los Estados Unidos.

Si bien es cierto que la enfermedad mental desempeña sólo un pequeño papel en la mayoría de las formas de violencia, incluidos los homicidios individuales, su papel es mayor en los tiroteos masivos.

Alrededor del 60% de los perpetradores de este tipo de tiroteos tienen un historial de trastornos mentales graves, y, de ellos, dos tercios nunca pisaron un servicio de salud mental, dijo Grant Duwe, director de investigación y evaluación del Departamento Correccional de Minnesota, quien ha pasado años estudiando los tiroteos masivos. Aunque eso sugiere una mayor necesidad de tratamiento, la tercera parte de los que sí recibieron ayuda “llevaron a cabo un ataque de todos modos”, dijo. “Así que, incluso recibir atención de salud mental no es la panacea que la gente dice que es”.

Por ejemplo, James Holmes, quien en 2012 mató a 12 personas en un cine de Aurora, Colorado, , y habló sobre pensamientos homicidas en las sesiones. Pero no fue reportado a las autoridades porque no expresó ningún plan concreto.

Seung-Hui Cho, cuyos problemas mentales se remontaban a su infancia, dos años antes de matar a 32 personas y herir a otras 17 en la Universidad Virginia Tech, en 2007. Diagnosticado con un trastorno del estado de ánimo después de amenazar con autolesionarse en 2005, fue hospitalizado durante una noche y un juez ordenó que recibiera tratamiento ambulatorio. Pero, misteriosamente, no fue evaluado ni tratado.

A menudo, la propensión de estas personas a la violencia es más fácil de ver en retrospectiva.

Seis meses antes del tiroteo en el Borderline Bar & Grill en Thousand Oaks, la policía respondió a una llamada al 911 que reportaba gritos y golpes procedentes del interior de la casa donde Long, el supuesto atacante, vivía con su madre. Al llegar, la policía se encontró con un joven “iracundo” que actuaba “irracionalmente” y llamaron a un equipo de crisis de salud mental. Los trabajadores sociales de ese equipo lo evaluaron y concluyeron que no había motivos para ponerlo bajo supervisión psiquiátrica.

No se sabe si los oficiales sabían que había manejado ametralladoras en Afganistán, lo que, después del tiroteo, llevó a que podría haber padecido un trastorno de estrés postraumático. Sólo más tarde se supo también que Long había atacado a un en la escuela secundaria.

California permite a las autoridades detener a las personas durante 72 horas para evaluar su estado mental, una práctica similar a la de muchos estados. Pero el estándar para este tipo de detenciones, conocidas en California como “5150”, es bastante alto, señaló el doctor Garen Wintemute, médico de emergencia, quien dirige el Centro de Investigación de Violencia con Armas de Fuego de la Universidad de California en Davis.

Para ser detenida, una persona debe representar una amenaza grave e inminente para sí misma o para otros, o estar tan seriamente discapacitada que no pueda cuidarse por sí misma. La ley no toma en cuenta el abuso de sustancias, dijo Wintemute.

“Un 5150 implica poner a una persona bajo custodia a veces en contra de su voluntad”, explicó Wintemute. “Eso no es algo que se pueda hacer a la ligera”.

El doctor E. Fuller Torrey, psiquiatra que fundó el Treatment Advocacy Center hace 20 años, ha argumentado durante mucho tiempo que la sociedad necesita ser más enérgica a la hora de proporcionar atención a las personas gravemente perturbadas —y exigir esa atención cuando sea necesario— para prevenir el suicidio, los tiroteos en masa y otros actos de violencia.

Su objetivo es lograr que más legislaturas estatales aprueben proyectos de ley como la Ley de Kendrall en Nueva York y la Ley de Laura en California, por las que los jueces pueden ordenar que las personas con enfermedades mentales reciban tratamiento ambulatorio. Su organización asistió en la redacción de ambos proyectos, y ha ayudado a conseguir la aprobación de leyes similares en al menos 16 estados. En California y algunos otros estados, sin embargo, el alcance de la ley depende de la decisión de cada condado para implementarla.

Duwe no se posiciona sobre la idea del tratamiento obligatorio, pero dijo que hacerlo para prevenir eventos que ocurren sólo unas pocas veces al año tiene poco sentido. “Los tiroteos públicos masivos son más comunes de lo que deberían ser, pero todavía no son tan frecuentes como para diseñar políticas basadas en el tratamiento de eventos tan raros”, expresó.

Las leyes de armas que se enfocan exclusivamente en personas con antecedentes de salud mental también tienen poco sentido, dijeron los doctores James Knoll y George Annas, profesores de psiquiatría del SUNY Upstate Medical Center, en un artículo de 2016 en .

Esas leyes “tendrán un rendimiento extremadamente bajo, serán ineficaces y derrocharán recursos escasos”, escribieron.

Wintemute sostuvo que otras intervenciones estratégicas podrían funcionar mejor. Por ejemplo, aboga por arreglar problemas en el sistema nacional de verificación de antecedentes, por el que se requiere que los vendedores de armas de fuego verifiquen con el FBI que un comprador no es un delincuente, un fugitivo, un abusador doméstico o un enfermo mental peligroso.

Explicó que uno de los defectos es que las ventas privadas están exentas de estos chequeos, incluyendo las que tienen lugar durante ferias comerciales de armas de fuego. Sólo las agencias federales, pero no las estatales, están obligadas a enviar información a la base de datos de verificación de antecedentes; y no se reportan miles de casos de violencia por parte de miembros del servicio militar, incluyendo el de un .

Wintemute también ayudó a redactar una ley de California que entró en vigencia en 2016 y que permite a los miembros de la familia, o a los agentes del orden público, solicitar una orden de restricción temporal que prohíba a una persona potencialmente violenta comprar armas, y confiscarle las que ya estén en su posesión.

Estas órdenes para restringir las armas de fuego no involucran una evaluación de salud mental, dijo Wintemute, pero están diseñadas para permitir que los miembros de la familia retiren temporalmente las armas de un pariente en riesgo de hacer daño, incluyendo el suicidio. La orden puede durar hasta tres semanas y puede extenderse hasta un año después de una audiencia, en la cual el dueño del arma puede pedirle al juez que se la devuelvan.

En California, se emitieron 190 órdenes hasta finales del año pasado, indicó Wintemute, algo que describió como decepcionante. Las cifras para este año aún no se recopilan, pero Wintemute dijo que están creciendo. Hasta ahora, 13 estados han aprobado leyes similares, comenzando con Connecticut en 1999. Ocho, incluyendo Florida, las aprobaron después del tiroteo en Parkland, y Florida ya ha emitido 450 de esas órdenes, señaló Wintemute.

Los médicos pueden desempeñar un papel clave al preguntarle a los pacientes y a los miembros de la familia si poseen armas y al animar a la familia a solicitar una orden de restricción si están preocupados, agregó Wintemute.

“Si los médicos están dispuestos a ver esto como `Si ves algo, di algo,’ y lo llevas a la atención de las familias, podríamos reducir los índices de suicidio y posiblemente los tiroteos masivos”, concluyó.

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Similarly, after a school shooting in Parkland, Fla., that killed 17 students and staff members in February, Trump tweeted that there were “so many signs that the shooter was mentally disturbed.”

Public health and mental health experts counter that blaming the violence on the mentally ill is unfair and inaccurate, pointing instead to lax gun laws. “Most violence is not committed by people who are mentally ill,” said Dr. Renée Binder, a professor of psychiatry at the University of California-San Francisco and a past president of the American Psychiatric Association. “Even if you took everyone who had any kind of mental illness and locked them up and gave them meds, it would hardly make a dent on the problem of violence.”

Post-shooting debates typically are painted in black and white — but research suggests that the truth is less clear-cut.

The “stigma-busting advocates,” who insist that mental illness has no connection to violence, and the “fearmongers,” who assert that “the mentally ill are a dangerous menace and should be locked up,” are both wrong, said Jeffrey Swanson, a professor of psychiatry at Duke University who has studied patterns of violence in major U.S. cities.

While it is true that mental illness plays only a small role in most forms of violence, including individual homicides, its role is larger in mass shootings.

About 60 percent of mass shooters have a history of serious mental disorders and two-thirds had never been seen by a mental health professional, said Grant Duwe, director of research and evaluation for the Minnesota Department of Corrections, who has spent years studying mass public shootings. While that suggests a greater need for treatment, the one-third who did get help “carried out an attack anyway,” he said. “So, even getting mental health care is not the panacea people make it out to be.”

For instance, James Holmes, who killed 12 people in an Aurora, Colo., theater in 2012, had been and spoken of homicidal thoughts. But he was not reported to authorities because he voiced no concrete plan.

Seung-Hui Cho, whose mental problems dated to childhood, repeatedly two years before he killed 32 people and wounded 17 others at Virginia Tech University in 2007. Diagnosed with a mood disorder after threatening to harm himself in 2005, he was hospitalized overnight and ordered by a judge to receive outpatient treatment. But, mysteriously, he was not assessed or treated.

Often, shooters’ propensity for violence is easier to see in hindsight.

Six months before the shooting at the Borderline Bar & Grill in Thousand Oaks, police responded to a 911 call about yelling and banging coming from inside the house where Long, the alleged shooter, was living with his mother. They found an “irate” young man acting “irrationally” and called in a mental health crisis team. The social workers on that team evaluated and concluded there were no grounds to place him under a psychiatric hold.

It is unclear whether the officers were told of his history as a machine gunner in Afghanistan, which after the shooting led to he might have had post-traumatic stress disorder. Only later did it emerge that Long had allegedly in high school.

California allows authorities to place people on a 72-hour hold to evaluate their mental states — a practice similar to that in many states. But the standard for such holds, known in California as a “5150,” is quite high, said Dr. Garen Wintemute, an emergency physician who heads the University of California Firearm Violence Research Center at UC-Davis.

To be held, a person must pose a serious imminent threat to themselves or others or be so gravely disabled that they can’t take care of themselves, he said. The law does not take substance abuse into account, Wintemute said.

“A 5150 involves taking a person into custody sometimes against their will,” Wintemute said. “That’s not something that’s done lightly.”

Dr. E. Fuller Torrey, the psychiatrist who founded the Treatment Advocacy Center 20 years ago, long has argued that society needs to be more forceful in getting care for the severely disturbed — and requiring it when necessary — to prevent suicide, mass shootings and other violence.

His goal is to get more state legislatures to pass bills like Kendra’s Law in New York and Laura’s Law in California that allow judges to order mentally ill people into outpatient treatment. His organization helped draft both those bills and has helped win passage of similar laws in at least 16 states. In California and some other states, however, the reach of the law is limited by whether counties decide to implement the approach.

Duwe takes no position on the idea of mandated treatment but said that doing so to prevent events that happen only a few times a year makes little sense. “Mass public shootings are more commonplace than they ought to be, but they are still too infrequent to design policies based on addressing such rare events,” he said.

Gun laws that exclusively target people with mental health histories also make little sense, said Drs. James Knoll and George Annas, psychiatry professors at SUNY Upstate Medical Center, in a 2016 article in .

They “will be extremely low yield, ineffective, and wasteful of scarce resources,” they wrote.

Wintemute argued that other strategic interventions may work better. He advocates fixing problems in the nationwide system of background checks, which requires firearm dealers to verify with the FBI that a purchaser isn’t a felon, fugitive, domestic abuser or dangerously mentally ill.

He said flaws in the law include the fact that private sales, including those at gun shows, are exempt; only federal, but not state, agencies are required to submit data to the background-check database; and thousands of cases of violence by military service members — including that of a in 2017 — are not reported.

Wintemute also helped draft a California law that took effect in 2016 that allows family members or law enforcement officials to seek a temporary restraining order barring a potentially violent person from purchasing guns and removing any already in their possession.

These so-called gun violence restraining orders don’t involve a mental health assessment, Wintemute said, but are designed to let family members temporarily get guns away from a relative at risk of doing harm, including suicides. The order can last up to three weeks and can be extended for up to a year after a hearing, in which the gun owner can ask a judge to return the weapon.

In California, 190 orders were issued through the end of last year, Wintemute said, results he described as disappointing. Numbers for this year have not yet been compiled, but Wintemute said they are growing. So far, 13 states have passed similar laws, beginning with Connecticut in 1999. Eight, including Florida, approved them in the aftermath of the Parkland shooting, and Florida has already issued 450 such orders, Wintemute said.

Physicians can play a key role by asking patients and family members if they own guns and encouraging the family to seek a gun order if they’re worried, Wintemute added.

“If physicians are willing to see this as ‘If you see something, say something,’ and bring it to families’ attention, we could decrease rates of suicide and possibly mass shootings,” he said.

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The twin measures in Palo Alto and Livermore, sponsored by the Service Employees International Union-United Healthcare Workers West, take aim primarily at Stanford Health Care, which operates Stanford Hospital and Clinics, the facility with the third-highest profits in the country from patient care services, according to a 2016 .

The union also is sponsoring Proposition 8, a statewide measure that would impose a cap on profits for dialysis clinics. Together, the state and local measures seek to draw on public outrage over sky-high medical prices. And, for municipalities, they amount to a novel and untested effort to rein in those prices through the ballot box.

“I’ve been in this field almost 50 years, and I’ve never seen a local government regulating hospital prices,” said Paul Ginsburg, director of public policy at the Schaeffer Center for Health Policy & Economics at the University of Southern California. A number of states set hospital rates in the 1970s, and two states, Maryland and West Virginia, do so today, he said.

Opponents question the legal authority of cities to regulate health care pricing, and they predict a flood of litigation against the measures if they pass. The city councils of both cities oppose the proposals, arguing that local officials with no expertise in health care costs would be required to create a new bureaucracy to regulate them.

Stanford Health Care officials say the measures could undermine quality. “It would threaten [the system’s] ability to provide top-quality health care to patients from Palo Alto and across the region,” according to a September statement from the system.

Ginsburg expressed skepticism. “Of course, you could cut rates too much and harm hospitals financially,” he said. “But if done with intelligence, you could accomplish some price reduction without harming quality.”

For the union, the ballot measures could help it gain leverage in future bargaining or organizing efforts with Stanford and other hospitals. Stanford Health Care operates the largest hospital system in both cities where the price cap proposal is on the ballot. Stanford has opened, has acquired or is building health care centers with clinics and specialty services in Emeryville, Pleasanton and Redwood City — Bay Area cities where the SEIU-UHW tried but failed to place similar price-control measures on local ballots.

But union officials say their motive is simply to rein in prices. “Stanford Health is nonprofit. They don’t pay property taxes or incomes taxes,” said Sean Wherley, an SEIU-UHW spokesman. “Taxpayers are subsidizing their operations and getting wrung out by over-the-top prices.”

Stanford and other health systems have been on a buying spree in recent years acquiring hospitals and physician practices, and this concentration of ownership has stifled market competition and further boosted prices for insurers and patients.

The Palo Alto and Livermore initiatives, which also affect other medical systems in the cities, would cap prices charged by hospitals and other health care providers at 115 percent of “the reasonable cost of direct patient care.”

And there, some experts say, lies the rub.

“What is a seemingly simple idea — limiting prices to 115 percent of ‘costs’ — is neither simple in execution, nor concept,” said Benedic Ippolito, a research fellow at the American Enterprise Institute who studies health care financing. “What costs are acceptable? How will we stop providers from increasing costs as much as possible” to compensate for the cap?

Under the initiatives, hospitals and other medical providers would be obliged to pay back any charges above the cap each year to private commercial — but not government — insurers, and to patients who pay for their own care. They would also owe the cities a fine equal to 5 percent of the excess charges. Fines collected by the cities could be used to pay for enforcing the laws.

Stanford estimates that Proposition F, the Palo Alto measure, would reduce the health system’s budget by 25 percent, forcing it to make cutbacks and possibly end essential services, said David Entwistle, the health system’s president and chief executive officer.

Livermore would need to spend $1.9 million a year on the staff required to implement Measure U — its version of the proposal — and would likely incur another $750,000 to $1 million in legal and startup costs, according to conducted for the city by Henry Zaretsky, a health economist who has worked for the state and the California Hospital Association.

Patients in the wealthy region expect high-quality services but also can be savvy consumers and passionate voters. It is an open question whether the measures would pass.

Industry consolidation is far more pronounced in Northern California than in Southern California, according to a from the University of California-Berkeley. As a result, inpatient hospital prices in the north were 70 percent higher and outpatient costs as much as 55 percent higher than in the south. The price disparities, even within the Northern California region, can be dramatic.

For instance, independent doctors in the Bay Area are reimbursed, on average, a median $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits, according to a 2017 Kaiser Health News analysis of claims data from , a health cost transparency company. That compares with $5,238.13 for the same bundle of services for Stanford physicians (and $8,049.84 for doctors employed by the University of California-San Francisco).

The higher cost of medical care also pushes up insurance premiums for patients. Health plans purchased on the state insurance exchange were 35 percent higher in Northern California than in Southern California, the 2018 UC Berkeley study showed.

Earlier this year, California Attorney General Xavier Becerra took aim at medical industry consolidation and the high prices associated with it. He , one of the nation’s largest health systems, saying it was systematically overcharging patients and illegally driving out competition in Northern California.

To C. Duane Dauner, a former president and CEO of the California Hospital Association, the ballot proposals are “a power play by SEIU-UHW to put pressure on Stanford Health Care.” The union wants Stanford “to be neutral when they try to organize employees in Redwood City, Emeryville, Pleasanton and Livermore,” said Dauner, who heads the campaign committee opposing both measures.

Larry Tramutola, a veteran campaign consultant who is not involved on either side, agrees.

“I don’t think it has anything to do with controlling health care prices,” said Tramutola, who recently managed successful local initiatives to tax sodas and ban menthol cigarettes. “It’s about bargaining. Win or lose on this, other hospitals in other places will take notice and realize that SEIU is a formidable foe.”

Protect Our Local Hospitals and Health Care, the campaign committee opposing the measures, has raised $4.2 million so far this year. The union’s political action committee has spent $1.5 million in support of the initiatives.

California Healthline senior correspondent Barbara Feder Ostrov contributed to this report.

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