What’s right and what’s and what’s to be done with mental health care? Joining Dr. David Gratzer on Quick Takes to discuss the topic is Dr. Thomas Insel, who researched and reported on the state of mental health care for his book, Healing: Our Path from Mental Illness to Mental Health.
Some highlights of this conversation include:
- acknowledgement that existing treatments work, but the system is not delivering care well.
- treatment tends to focus on drug therapies for symptom reduction rather than on plans for long-term recovery
- care is often unaffordable and unavailable, particularly for those who need it most and are experiencing homelessness
- and the key to recovery involves the three Ps – people, place, and purpose.>
June 22, 2022
An Interview with Dr. Thomas Insel, former NIMH Director
[Edited for grammar and clarity by CAMH]
David Gratzer: The scientific progress in our field has been stunning. But the public health outcomes got worse. Criticism of mental health care is not uncommon, but Thomas Insel isn't the sort of person we typically assume to make such comments. Dr. Insel has had extraordinary career. He's the former director of the National Institute of Mental Health and has overseen over $20 billion worth of grants for research. He's also the author of a new book on mental health care. And today he joins us on Quick Takes to talk about what's right, what's wrong and what's to be done with mental health care. I'm Dr. David Gratzer. Welcome, Dr. Thomas Insel.
Thomas Insel: Well, thank you for having me, David. It's a real pleasure to be here, as I was just saying, I'm a huge fan of what you're building and what you've done with your weekly review of the research literature. So it's great that we have this opportunity to talk.
David Gratzer: That's very kind. You've done many interesting things in your career. And before we talk about the book, you actually co-lead President Obama's BRAIN Initiative. Did you not?
Thomas Insel: Story Landis and I together co-led the BRAIN Initiative, and it was really one of the great privileges of public service at that time. President Obama had this idea that he wanted to make huge changes in brain disorders, but he, as he said, you know, we're really not ready to do that until we have the tools. So he said what he wanted, and these are his words, is he wanted the tools that would allow us to study the brain at the speed of thought.
David Gratzer: You raise a lot of questions in your new book, why did you decide to write this book?
Thomas Insel: Yeah, it's a great question. I'd always had this idea when I watched the film Inconvenient Truth in 2006 I was like blown away and I thought, it's so important that somebody calls attention to the things hiding in plain sight. At that point, it was climate change. And I thought to myself, we need to do that for mental health. But I was so busy with 18 other things. I was at NIMH and I wasn't really clear on how to do it and when to do it or where to do it. So I kind of just buried that idea until about 10 years later. And I was giving a talk at a public event on the West Coast and presenting where we were for NIMH. It was to mostly family members. And I was putting up all this fantastic science, I was showing how we had like, you know, great advances with stem cells at that point where genomics was taking us the ability to like from the BRAIN Initiative, what we were able to do with neuro technologies. And afterwards, somebody got up and said, Man, you just don't get it. You just don't get it. My son has schizophrenia. He's 23. He's been hospitalised several times. He's been in jail several times. He's currently homeless, eating out of a trash can. Our house is on fire, and you're talking about the chemistry of the paint. And that was really kind of an epiphany for me because I, you know, on the one hand, I thought, well, like, you don't get it, man.
Thomas Insel: I mean, this is like science as a marathon, it's not a sprint. These are hard problems. But the more I thought about that, the more I had to say, like, you know, here I was enjoying what was really kind of a golden age for clinical neuroscience because of advances in cognitive science, advances in imaging, our ability to study brain, behaviour, mood, cognition, all this in a really precise way that we hadn't before. It was a fantastic time to be a researcher and to be in the scientific vanguard of that and to be part of like the brain initiative. How cool is that? The same time in the years I was at NIMH the suicide rate in the United States went up 30 percent, and those years the overdose death went up 300 percent. The number of people with serious mental illness who were working, who were housed, who were not incarcerated, all those numbers went down, not up. We were on almost any public health measure you want to look at. We were losing ground at the very same time that we were making so much progress on the science. And I wanted to try to understand that problem. I wanted to understand why we had succeeded on the science and failed on the public health side and what it would take to close that gap.
David Gratzer: And that is what your book and your speeches and your writing is about. What are some conclusions you've made?
Thomas Insel: Well, the first thing I did, you know, so I spent several years in the tech industry, so my first thought was, well, the care system is broken. This is we're in a crisis, but it's a crisis of care. Unlike the COVID crisis, which was an emerging illness, we have an increase in prevalence. But that's not what's driving the crisis. What's driving the crisis is a broken system. It's fragmented, it's episodic. It's a sick care system, not a health care system. We're looking at all the wrong problems and we're trying to do this in the most expensive, most intensive and the least effective way possible. And so I came around to sort of saying like there are three things that we need to fix here. And actually, each of them were things that the tech companies are very good at. So we need to figure out engagement. One of the reasons we haven't made progress is that people who need treatment the most or the least likely to get it.
The second was that. We have a quality problem. We have good treatments, but the workforce we have doesn't deliver the treatments that work in the way that we know they're effective. That's a problem. It's a quality problem, not just an access problem, a quality problem. The third problem for me was just this in our field, almost a total lack of accountability. What do I mean by that? Well, we don't measure outcomes. Only about 18 percent of providers measure anything in the course of their practise in the United States. So this concept of measurement-based care, which I think all of us understand, is absolutely vital to improving outcomes. So there's those three things engagement, quality and accountability are the things that we would need to fix the care system, and there's a lot to unpack in each of them.
But David, I think the point to make as I got deeper and deeper into this was to realise that it's not just about the care system. I mean if we if we really care about mental health, if that's the goal, we have to talk about more than mental health care. There's a lot more going on here. Some of it has to do with your zip code, not your DNA code. Some of it has to do with the environment where your lifestyle, your, you know, your social support network, all of these things that we're not really focussed on in the care system. So where the book ends up is actually in a very different place than where I started because I started this when I was still very much in the tech world and thinking that we were going to find the right software and hardware to solve this problem, to solve the crisis. And I ended up thinking that. We've got to really go in a much broader way at this set of issues that are one thing. We have to instead of thinking that this is all about a care built around reducing symptoms, we've got to think about recovery. We've got to think about how do you give people a life? I was talking to a psychiatrist who works on Skid Row in Los Angeles and he was the one who said, you know, Tom, if you really want to make a difference, stop thinking about diagnosis and symptoms, start thinking about recovery.
And I thought, like, all right, so what is that? He said, it's simple. It's just the three P's. And I thought, All right, you got Prozac, you got Paxil or psychotherapy. That's that's actually, you know, technically, that's a p, right? And he shook his head. He said, No, look, it's people, place and purpose. Social support, a decent environment with housing and food and things that help people to prosper. And people will have have a reason they have to have something to live for. If you want to reduce suicide, make sure people have something to live for. So those three P's people place and purpose is what the book is built around. Ultimately, and yet they're not part of our mental health care system. It's not what we do. We make sure that people have Paxil, Prozac and maybe psychotherapy or psychological services, but we are not focussed on that recovery model. And it took me a long time to get to that, and I have to say I'm a reluctant student here I. Um, I'm a scientist and I believe deeply in the kind of medical model for solving these problems, but I have to say I don't think it's worked. I don't think it's served us and we have to start thinking about not just doing more of the same, but doing something quite different. And that different to me is defined by the three P's.
David Gratzer: Your book does talk about biological interventions that work. You talk about ECT. You talk about medications. You talk about a person who struggles with a postpartum depression. But you talk about many things that one wouldn't necessarily expect the former director of the NIH to talk about. It's a big shift for you.
Thomas Insel: Yeah, it's a shift that came about when I stopped being a psychiatrist and started being a journalist. Um, you know, when I was starting to write this book, actually, I wrote it initially and it had like 100 figures and tables in it, and it was really a policy book that I put together and I was sharing it with a friend who's a very good journalist for the New York Times. And he said, forget this. He said, look, if you want to tell this story, sleep under a bridge in Oakland for a couple of nights and listen to the stories. Think about this. Immerse yourself in this world, not in the papers, not in the literature, but in the lived experience of people with serious mental illness. Find out, like you're telling us that they don't engage, so why not? Like, what's the problem? And that was actually extremely good advice. So it was the result of spending a year in clubhouses and homeless shelters and jails and prisons. I mean, just spending a lot of time with people who have serious mental illness, but they're not coming to us. They're not in our, you know, they're not part of our medical system, our health care system. They are largely living outside of that and we're not meeting them where they are.
And so that's why I began to have a very different view. And that's where the three P's and all of that comes from. But, my point, and I guess like the last part of the book, I essentially say the problem is medical. These are brain disorders, and we need to make sure that they get the same rigour and the same quality and the same reimbursement as any other medical problem. But the solutions are not just medical, the solutions are relational, they're environmental, they're political, there's a lot of other things. If we're serious about mental health and not just mental health care, if that's what we care about, then we've got to broaden the lens and we've got to start to take in lots of things that we haven't been really looking at in our care system.
David Gratzer: Your travels, in fact, take you to Italy. What did you discover there?
Thomas Insel: Yeah. Well, there's the programme in Trieste, which has been developed over 50 years. It's gotten a lot of international attention. And what you see in Trieste is really kind of whole person care. It's trying to make sure there truly are effective community services that patients have agency, that families are part of the solution. When a young person is psychotic, there's a team that goes out and spends several hours at the house and the team includes a peer who can who's been through this and can help to both educate the family and build a bond with the person who's really struggling in that crisis moment. So Trieste, I think, has done a really pretty wonderful job. They do have inpatient services, but it's all integrated in a way that is both comprehensive and continuous. Now I think it's important to look at that and study those examples of success. But, you know, they also don't have a meth epidemic or an opiate epidemic. They don't have a lot of the issues that we deal with in a lot of our large cities. So, it's not like as simple as just saying, we're going to buy that and put it in place. You can't cut and paste some of these models, but you can learn from them and there are pieces of them that you can really think about how to implement. And I would say the crisis system in a place like Trieste is really important to learn from.
David Gratzer: In contrast, to say what somebody who's experiencing psychosis might have happened to him here. You write quite lucidly in the book about the police coming out and sitting in emergency department for three days. A person being restrained. We get a lot of things wrong here, don't we?
Thomas Insel: We could do them better, I don't think most police officers want to be social workers, and I don't think most families want to see their kid with a brain disorder carted off to jail. They certainly want one would not want that if their kid had a diabetes or a broken leg. They kind of hope that that they get health care and not end up in the criminal justice system. But I mean, today you look at the numbers. We've got about 350,000 people in the criminal justice system with serious mental illness and about 35,000 in our public mental health hospitals across the United States. So as a 10 to one ratio there. That's not the story for any other medical problem I can name.
David Gratzer: You talk about how de-institutionalisation in the nineteen sixties was really trans-institutionalisation and of course, others have spoken about that as well, that that there are fewer people in psychiatric hospitals and facilities and that they've ended up in fact in the jail system that they've not been de-institutionalised. They've been institutionalised just in another way.
Thomas Insel: Hard to see that as progress. I just don't think it has to be that way. We didn't do that when I was in training. We didn't have a lot of homeless people with serious mental illness when I was in training. A lot of what we've just come to accept in 2022 would have been unthinkable in 1982. It just didn't look like this. So when people ask me, you know, is this even possible? I have to say, yeah, this used to be us. We knew how to do this. So a lot of this isn't necessarily innovation. It's going back to building the social safety net that we once had and helping families to manage these problems in a very different way
David Gratzer: Some of our listeners today are psychiatrists in practise. Some of our listeners today are psychiatrists in training, residents. What would you like to say to them?
Thomas Insel: I think we're in a historic shift right now, I think things are changing in a way that I could not have foreseen before. And I am hopeful. I mean, I think you're involved in a part of medicine, which is maybe the least appreciated, but in some ways the most important. There is no doubt going to be a real push to make psychiatry just like the rest of medicine, but my message would be don't go there. We don't need to be like the rest of medicine. The problems that we're dealing with are categorically different. And I must say, you know, that was not where I was when I started the book, which was to make the case that there's nothing different about mental illness. It is just a medical problem like diabetes or hypertension. That's not where I ended up. I think it is different and we should be different. And I and I think what could be different in good ways. But that means preserving what we do really well, and that includes this kind of whole-person approach. That's just thinking about more than just a reduction of symptoms, which is what medicine does. Thinking about more than just the classic medical model borrowed from infectious disease: simple bug, simple drug. Let's find the vaccine. I think that's OK. We should be doing that as well, but we can, and we should do so much more.
David Gratzer: Dr. Insel, it is a tradition of Quick Takes that we close with a rapid-fire minute, so we're going to put a minute on the clock. And we're going to ask you a series of questions. Are you ready, sir?
Thomas Insel: Ready for Quick Takes? Ok, let's do this!
David Gratzer: One minute on the clock. Here we go. Best response you've received for your book so far.
Thomas Insel: Oh, Library Review.
David Gratzer: The great biggest surprise in writing this book.
Thomas Insel: On that, health care is two words.
David Gratzer: What's your next project?
Thomas Insel: I want to work on creating a social movement for mental health. So the book will be a flagship for that, but I want it to be a fleet that includes a digital publication, a social media campaign, some additional advocacy and then efforts like the Ken Burns documentary that will be out in June.
David Gratzer: What have you enjoyed most about this project?
Thomas Insel: The I love writing. Because it I started the book because I was trying to understand something I couldn't understand. And the deeper I got into it, the more confused I got and then staying with it. I ultimately, mostly because of really good conversations, began to understand what had been so confusing. And so what I enjoyed most was kind of, somebody said, going from simple to complicated to simple again. Getting back to simple again was really was really satisfying. And I should say a lot of this book I wrote mountain biking in the hills around my home in the East Bay of the Bay Area near San Francisco. That was the most, most delightful and the most effective way for me to write. This was to get on my bike and charge off into the wilderness.
David Gratzer: Perhaps a metaphor for the book itself. And at the at the buzzer, are you on a first name basis with President Obama?
Thomas Insel: No, I am not I. I'm a huge admirer of both the President and the former first lady, but no such luck.
David Gratzer: The book is called Healing: Our Path From Mental Illness to Mental Health. It's available at bookstores and, of course, online bookstores, and it's it's a great read and an amazing book, a very important book.
David Gratzer: You've got a website.
Thomas Insel: I do. Thomas Insel, MD dot com.
David Gratzer: And where do the proceeds from the book go?
Thomas Insel: So my next project is MindSite News dot org. It's a non-profit journalism project. We're using the book to launch MindSite News, and it's a little bit like Stat News. It's a daily newsletter, a weekly research roundup that I do and and we have some fantastic journalists who provide content all on this kind of overlap or intersection of mental health and social justice issues.
David Gratzer: We appreciate your time. We really appreciate the book.
Thomas Insel: Thank you so much, David. It's been a real pleasure chatting with you.
David Gratzer: It's been a pleasure.
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Until next time.