Short Wave - Dr. Thomas Insel On Why The U.S Mental Health System Has Failed And What Can Be Done

Episode Date: March 7, 2022

For over a decade, Dr. Thomas Insel headed the National Institute of Mental Health and directed billions of dollars into research on neuroscience and the genetic underpinnings of mental illnesses. Health correspondent Rhitu Chatterjee talks with Dr. Thomas Insel about his new book, Healing: Our Path from Mental Illness to Mental Health and how he came to realize where the U.S's mental health care system had failed, despite scientific advances in the field.See pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences.NPR Privacy Policy

You're listening to Shortwave from NPR. For over a decade, psychiatrist and neuroscientist Dr. Thomas Insel headed the National Institute of Mental Health and directed billions of dollars into research on neuroscience and the genetic underpinnings of mental illnesses. Our efforts were largely to say, how can we understand mental disorders as brain disorders, and how can we develop better tools for diagnosis and treatment? But in the very first pages of history, new book, Healing, Our Path from Mental Illness to Mental Health, he admits that despite that

research, Americans continue to struggle with mental illnesses at increasingly high rates. Insel says that's because the U.S. mental health care system is broken. Today on the show, Dr. Thomas Insel shares how he came to realize where America had failed and his journey to find the answers to addressing the country's mental health crisis. I'm Ritu Chatterjee and you're listening to Shortwave, the Daily Science podcast from NPR. I want to start with your time at the National Institute of Mental Health. What were some of the scientific discoveries you oversaw during your time there? There was a range of interesting projects.

We did several large clinical trials, which I must say, I think overall, these were trials for depression, for schizophrenia, for bipolar disorder. The bottom line from most of those was that in the real world of care, our medical treatments were not as good as we thought. And I think that was an important insight that really charged us to say we've got to do better in terms of developing more effective medications. At the same time, I think we had a greater awareness, particularly in the later years of my tenure, that we could begin to combine treatments in a way that was very effective.

And where we saw this the most was in how we began to address, the first episode of psychosis for young people with a disorder like schizophrenia or with a form of bipolar disorder. And here what we began to understand with something that ultimately became what we now call coordinated specialty care, was that by combining medication and psychological and cognitive therapies and bringing in families and giving agency to the young person involved, providing academic support and employment support, we could actually help kids recover and that we could get to a point where kids who had had a first episode of psychosis weren't destined to have a second episode. Yeah, and that sounds significant. But overall, would you say these discoveries and developments, did they really translate into greater mental health for Americans?

Well, Ritchie, one of the things that I struggled with was trying to understand this gap between our scientific, scientific progress and our public health failure, I think we've got to understand why it is that we've been able to do so well on the science and so poorly on the delivery of care for the 14.2 million people with serious mental illness in this country. And part of this is we have a broken care system. Why don't you tell me about the time that you were giving a public talk and were sort of forced to confront this paradox. And how did it really change your understanding and, like, lead you to kind of what you just said

that you've really tried to understand the sort of gap between the discoveries and the labs and public health implementation of those treatments and systems of care? I was at a talk I was giving to a large group of family members, largely, And it's about 2014, 2015. And as I was showing them, a spectacular success we had had with stem cell studies of neurons and schizophrenia or what we were able to do for mapping specific genetic variants for autism, how we had created great models on the epigenetics of stress and depression.

And somebody got up at the back of the room and said, you know, I have a lot of the way. a 23-year-old son with schizophrenia, he's been hospitalized five times, he's been in jail, three times, he made two suicide attempts. Look, man, you know, our house is on fire, and you're talking about the chemistry of the paint. And I was initially quite defensive in my first reaction was to say, come on, come on, you know, science is a marathon, it's not a sprint. But, you know, there was a part of me that realized that the pain that he and so many other people were feeling had an urgency to it that our science wasn't addressing. And that's ultimately why I left the NIMH,

initially going to Silicon Valley and working in the tech industry, and later getting more and more involved with trying to start what is essentially a social movement to bring attention to the fact that this house is on fire, we're in a crisis in terms of mental health. This is a crisis of care. This is our failure to be able to provide the things that we already have in hand, the things that we know work. So tell me about those things. Yeah, absolutely. So, you know, most of the time when you talk about serious mental illness, that means schizophrenia, bipolar disorders, severe depression, perhaps eating disorders. There's a list.

And most of the time when you talk about treatments, people immediately get into a conversation about medication. Is America overmedicated? Is it undermedicated? Are the medications actually safe? Are they effective? All of that is a conversation we have to have. But I think it's important to realize that medication is a small part. It may be a necessary part, but it's a completely insufficient part of the care of somebody with a serious medication. illness. There are psychological supports that are critical. There are family interventions that are really effective in some ways. As effective long-term as what you see with medications, there are extraordinarily important forms of sort of rehabilitative care like housing support and supportive employment, supportive education, things that help people to get a life. Can you give one of the examples that you have in the book in terms of, like, real people you have spent some time with, explain sort of what you're talking about, what does recovery look like and what does it really take?

You talk about the importance of people, place, and purpose and how that's key. So I was talking to a psychiatrist who works on Skid Row in Los Angeles. And he said this. He said, you know, we really need to be thinking about recovery, not just acute care. here and I said, look, all right, so what is that? What do you mean by recovery? He said, it's just the three peas, you know, and I thought to myself, all right, you got three peas. They got Prozac, you got Paxil. What's that third P? I could be, I guess it could be psychotherapy, because technically that's a P. And he kind of just looked at me, you know,

out of the corner of his eye, shaking his head, and he said, look, it's really simple, man. It's It's people, its place, and its purpose. Those are the three P's. We don't address those three P's in our traditional medical care, but if we want people to recover, if we want to see someone have a life, we have to think about people, social support. We've got to make sure they have a place, a sanctuary, where they have a reasonable environment with reasonable nutrition

and a place that they know is home. And they need a purpose. The way I've come to think about it more and more is that if you're a runner and you break your leg, you need that acute medical care to get the leg repaired. But it takes you months and months and months of hard work to get back to running again. And we understand that.

And by the way, we even support. support that and pay for it. And we call that rehabilitative care. And it's hard and it takes a long time. But you have a psychotic break and somehow people haven't quite come to terms with the fact that it takes a year or more to fully recover and get back into the race. And the result is that many people don't. They don't actually get through.

and the whole process of recovery, and they may not get the rehabilitative care. Often it's not even paid for. I should say usually it's not even paid for. In July of this year, we'll have a new three-digit mental health crisis line, 988, available for people to call from anywhere in the country. And as you write in the book,

and as many mental health advocates have said to me over the past couple of years, that they see the launch of this number as an opportunity to create a better system of care for mental health. Tell me about a couple things you'd like to see happen. Well, two things. One is, I think we have to understand that 9-8-8 is not 911 for mental health. In 9-1-1, you have a dispatcher who you call, and they contact a first responder who comes to help. 9-8-8, the person you call is the first responder.

This is telehealth. And most of the crisis can be dealt with, something like over 90% of them will be dealt with by that person who's on the other end of the 988 line. So we have to get really smart about thinking about what the training is like, who those people are, and really understand that they're not dispatchers. They are truly telehealth professionals who are essentially both. the person answering the phone and the ambulance. The second thing that is absolutely vital and is often overlooked here is that 9-88 is just part of the whole continuum that we need. Yes, we need a place to call, but we also need a person to come

or people to come. We need the mobile response that's tied to this. And for some people, we're going to need a place to go. That means not, hopefully not jail and hopefully not a medical surgical emergency room where we now have this crisis of people being boarded for many, many days of time with mental health problems. But we need places like crisis stabilization units, psych emergency rooms, opportunities for people to spend maybe 23 hours, maybe seven days to be able to, to recover from whatever that acute crisis is.

So all three of those, the person to call, the people to come and the place to go, need to be part of our crisis response system going forward. As the states begin to implement this, otherwise it's like a highway in which you've put in, you know, some very nice new lanes, but the traffic just jams up at the next part of the highway that hasn't been fixed.

That's Dr. Thomas Insel, the former head of the NIMH. His new book is Healing, our path from mental illness to mental health. This episode was produced by Thomas Liu, edited by Laurel Dalrymple and senior supervising editor, Jaselle Grayson, and fact-checked by Catherine Seifer. Andrea Kissick runs the science desk. Edith Chapin is the executive editor and vice president of news, and Nancy Barnes is our senior vice president of news. I'm Rithu Tadji, and you've been listening to Shortwave, the day, Science podcast from NPR.