The One You Feed - Why We Need a Different Approach to Mental Health & Wellness with Dr. Tom Insel

Episode Date: May 23, 2023

Dr. Thomas Insel, a highly respected mental health expert, found inspiration in an honest comment from a frustrated family member. He was speaking to a group of mental health advocates about the advances in research and treatment when a man stood up to tell him that their family’s house was on fire, and Insel was only discussing the chemistry of the paint. This striking remark compelled Insel to reevaluate his priorities and look for ways to make a real impact on mental health care. He went on to work at Google, where he believed technology could help scale the proven therapies and treatments he had been researching. In this episode, Eric and Dr. Insel discuss why we need a different approach to mental health and… How to recognize the essential role personalized mental health care plays in improving well-being. How to determine the powerful influence of peer support and professional interventions in mental health recovery. Understanding the benefits of adopting an outcomes-focused mental health policy. Unraveling the challenges of addiction and the need for effective understanding and treatment approaches. The urgent need to assess the opportunities of incorporating mental health treatment into other health care programs for holistic care. To learn more, click here!See omnystudio.com/listener for privacy information.

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Throughout time, great thinkers have recognized the importance of the thoughts we have. Quotes like, garbage in, garbage out, or you are what you think, ring true. And yet, for many of us, our thoughts don't strengthen or empower us. We tend toward negativity, self-pity, jealousy, or fear. We see what we don't have instead of what we do. We think things that hold us back and dampen our spirit. Thank you. people keep themselves moving in the right direction, how they feed their good wolf. I'm Jason Alexander. And I'm Peter Tilden. And together, our mission on the Really Know Really podcast is to get the true answers to life's baffling questions like why the bathroom door doesn't go all the way to the floor, what's in the museum of failure, and does your dog truly love you? We have the answer.

Go to reallyknowreally.com and register to win $500, a guest spot on our podcast, or a limited edition signed Jason bobblehead. The Really Know Really podcast. Follow us on the iHeartRadio app, Apple podcasts, or wherever you get your podcasts. Thanks for joining us. Our guest on this episode is Dr. Thomas Insell, an American neuroscientist, psychiatrist, entrepreneur, and author who led the National Institute of Mental Health from 2002 until 2015. Prior to becoming the director of NIMH, he was the founding director of the Center for Behavioral Neuroscience at Emory University in Atlanta, Georgia. Tom also co-founded Humanist Care, NeuroWell Therapeutics, and Mindsight News, and is a member of the Scientific Advisory Board for Compass Pathways. Today, Tom and Eric discuss his book, Healing, Our Path from Mental Illness to Mental Health. Hi, Tom. Welcome to the show. Eric, good to be here. Delighted to

have a chance to chat with you. Yeah, I'm excited to talk with you about your book, which is called Healing, Our Path from Mental Illness to Mental Health. But before we get into that, we'll start like we always do with the parable of the two wolves. In the parable, there's a grandparent who's talking with their grandchild and they say, in life, there's two wolves inside of us that are always at battle. One is a good wolf, which represents things like kindness and bravery and love. And the other is a bad wolf, which represents things like greed and hatred and fear. And the grandchild stops, they think about it for a second, they look up at their grandparent, they say, well, which one wins? And the grandparent says,

the one you feed. So I'd like to start off by asking you, what does that parable mean to you in your life and in the work that you do? In listening to that parable, the thought I have is actually less about the personal and more about the policy. I'm very frustrated with mental health policy today with the way that we are spending quite a bit of money and getting really poor results. And for me, it's because of the wolf that's being fed. It's because the incentives are all out of line. So we are essentially feeding the wolf that is about, we'll call it greed, but it's really about commerce. It's about a medical industry that I think does make sense in the care of cancer and heart disease and maybe diabetes, but it really doesn't work or doesn't deliver for people who have a range of emotional problems from anxiety, depression, on to more serious mental illnesses like bipolar disorder or schizophrenia. And so my concern is that we have built a system. Some

people would say it's not a system, but we built a set of policies all to feed that particular wolf and probably good for some payers. And it seems to be pretty good for the pharma industry, but it's really not that great for families. It's not that great for patients. It just hasn't worked out for us. So anyway, that was my first association with the two wolves. Yeah. And I think to say that the rest of the health care system is working well in comparison gives you a sense of perhaps just how bad the mental health system might be. Fair point.

That's right. That's right. Let's start off with talking a little bit about your role at the National Institute of Mental Health. You were the director of it. You often were referred to as the nation's psychiatrist. this book. And I want to ask a question about that because you reference early on a pretty important moment where you realized that you had been helping guide policy towards a lot of money into research and development and felt very optimistic about that and that that was the path forward. And then some things started to happen where you started to say, well, maybe that's not the whole picture. Can you share a little bit more about that? Sure. Yeah. And I was in that role for 13 years. Just for context, the National Institute of

Mental Health is part of the National Institutes of Health, the NIH. It has 27 institutes and centers. And the NIMH, Mental Health Institute, is one of the larger ones. The budget currently is about $2 billion a year. So it's a significant amount of money, all devoted to research. It's a scientific agency within the federal government. This has its own laboratories and clinics, but it also, about 90% of the money goes out the door to support academic scientists around the country, even around the world. And the basic mission is to try to figure out more about, in the case of this institute, mental illness with the idea that we can do better on diagnosis and treatment going forward. So it's a bit of a public health mission.

So it's a bit of a public health mission. As I say in the book, I was giving a presentation on much of the work that the Institute was doing, as well as the Obama Brain Initiative, which I helped to direct along with others. And it was a group of people I was talking to were mostly family members and advocates in the mental health space. And at the end, somebody got up and said, man, you just don't get it. You know, I have a son who's 24 years old. He's been hospitalized four or five times, been incarcerated a couple of times. He's made a couple of suicide attempts and he's currently homeless. And we don't even know where he is. Our house is on fire and you're telling us about the chemistry of the paint.

And that was kind of a seminal moment. That was a bit of an epiphany for me where I had to say, whoa. On the one hand, I kind of was defensive, but I had to recognize that he had a point that the needs for mental health care had become urgent. And actually, we had good things to offer based on all the science that had been done, based on the work of places like NIMH. So we had a lot to offer and it wasn't getting out there. And I began to ask myself, how much more of my time do I want to spend on the research and discovery side? I think saying it's the chemistry of the paint is pejorative. I actually think we need to understand the chemistry of the paint. And I think there's a lot of hope

and a lot of promise coming from science. But at some point, you have to be accountable. At some point, you have to say, okay, you know, we've spent a lot of money. We've done a lot of science. We've written a lot of great papers. We have some interesting insights and even products to offer. Why aren't they getting out there? Why aren't we actually having a public health impact? And what does it take to make that happen? And that was the moment where I started to say, well, maybe the academic scientific community is not the community to do that. I mean, they with the largest marketing company in the world, really, which was Google and through Google search and Google ads, that maybe there would be an opportunity to actually have a bigger impact than what we were able to do through the academic research. Yeah, I think it's interesting. It makes me think, as you were

talking, it made me think a little bit about having the right vaccines that can at least help with a problem. And the problem being that people aren't getting them in the way that they need to get them. They're not getting access to them. They don't know what to take. There's no continuity to make sure that you actually take all three doses of it, right? That that framework is totally missing. And so while we could continue to improve vaccines and should, if they're not getting to people in a way that's actually helpful, that seems to be a pretty important place to focus. Yeah. Some people have taken this as an indictment of the NIH or the NIMH. It actually isn't. I think we need those folks to do what

they do. But we need something else. Yeah, we need to keep creating vaccines, but we need to be mindful of how to deliver vaccinations as well. And who's going to do that? And how does that happen? And that is, in some ways, part of what you want the private sector to do, or maybe a public-private partnership that begins to evolve. I think it's super relevant to the question about psychiatric or psychological treatments. We have, like, for instance, while I was at NIMH, we did a lot to focus on anorexia because it's one of the most fatal psychiatric disorders.

And I'm proud to say, I think we funded the development of some really significant advances. But even now, a decade later, there's just a handful of people who are trained to do those psychological interventions on teenagers with anorexia. Fortunately, that's a theme that's been picked up by a startup that's actually grown very quickly. It's probably delivered more of the bespoke therapy that we know works to more people with better results than we could have ever done in a brick and mortar one by one clinic. So there is hope. And I do think that there are ways to scale what we want to deliver through technology, but it's been a slow burn. It hasn't happened as quickly as I'd hoped. Yeah. Before we get into some more of what can we do to improve, I'd like to start by just getting clear on when you talk about mental illness or you talk about mental health,

what do those two things mean to you? And then from there, I'd like to then get even more specific and talk about what serious mental illness is, what that means and the distinction. Yeah, it's a good framing discussion to have. There's no great definition of mental health. Freud used to define it as the ability to love and to work, which isn't such a bad place to start. place to start. It's probably a little easier to talk about mental illness in terms of now it being defined by a manual that has a set of signs and symptoms. And if you meet criteria, then you get a diagnosis. So mental illness is medical, tends to be constrained by these diagnostic categories. And serious mental illness is nothing more than

the deep end of the pool. It's those people who have that group of illnesses like schizophrenia, bipolar disorder, schizoaffective disorder, which is kind of a mix, sometimes severe depression or severe PTSD, those disorders that cause enough disability to put you in that deep end of the pool, that is people who are not able to function because of their mental illness. We think there are about 14, maybe 15 million people who meet the definition of serious mental illness. The number of people who meet some criteria for some mental illness is in the 40, 50 million range in the United States. And of course, many of those have something that's fairly minor. You know, having a spider phobia would be a mental illness, but it doesn't really lead to you being very disabled in most cases. One other, I think, really important distinction to make while we're talking about language is that when we talk about health or mental health, pretty quickly we start talking about

health care and mental health care. And I think it's an important moment to say, hold on, health is not just health care, right? That if you look at what predicts health, just healthcare, right? That if you look at what predicts health, what are the determinants of health? Healthcare is one of them, but it's maybe 10, maybe 20% of ultimate determinants of what gives you longevity, what gives you well-being. So health is something quite different. It has a lot more to do with where you live, who you live with, how you live, what you live for. All of those things are much stronger predictors of health outcomes than your health care. I think that's the distinction we often overlook in the United States when we quickly start talking about health care, when we want to really be talking about health.

Right, exactly. And I think it applies 100% in the same way to mental health and often the very same things that predict good overall health, maybe predict is the wrong word, that could be determinants of good overall health are also tend to be good for our mental health at the same time. Like there's a lot of overlap there. Yeah, exactly. I think that's really true. This sort of gets us into having to come up with some better language. So like, Eric, love your thoughts about this as well. I've become really intrigued by recovery as a better term to be talking about when we start to talk about health and healthcare. I think it's really significant for us that, this gets back to your two wolves question, that recovery is a goal, is something that we can point to,

is something that we can define, something we can work towards. Not actually clear that much of what leads to recovery is within the healthcare system or gets reimbursed with healthcare dollars. We can unpack this a little further, but I'm pretty invested in this issue right now because it feels to me that in a country that's spending $4.3 trillion on healthcare, those agencies that are focused on recovery shouldn't just be existing on bake sales and galas, right? What they do, which is so significant for health, delivering recovery services ought to be considered like a really significant part of healthcare because they are really delivering health

outcomes. And yet they're largely nonprofits. They may be staffed by volunteers. It's kind of weird to me. In the mental health space, when we're talking about recovery, we're talking about sort of nonprofit community-based organizations often that are struggling just to keep operations going. Whereas, you know, in this kind of adjacent or parallel universe of medical care, if someone's on dialysis or they're having to recover from chronic renal disease, they never actually get to recovery until they get a transplant. But nobody expects dialysis to be paid for through bake sales. way up. But nobody expects dialysis to be paid for through bake sales. And nobody expects that if you're, you know, even getting physical therapy after a car accident, that that's something that doesn't get supported as you recover your physical capability, that that's course, going to get paid for through health insurance. And yet recovery on the psychological side, on the behavioral side, it's somehow considered qualitatively different that you leave that to volunteers.

You leave that to the world of community-based nonprofits. I don't get that. And I don't think we should accept that necessarily. So I've been thinking a lot about that double standard. Right. Lack of parity. There's a lack of, you point this out in the book, often sort of continuing care, right? There's no continuity of care for somebody with mental health, right? It tends to be you're on one end of a spectrum. Your primary care doctor is giving you a pill and that's it. Or you're being hospitalized in a psychiatric unit, but there's a whole world in between that is not being well tended to. I think your point about recovery, I think it's an interesting model. The term recovery is very helpful. In some ways,

I think it's a little bit of a misleading term because for most people who are going through an addiction or a serious mental disorder, you're actually not going to recover who you were. You actually emerge into somebody new and different. And so to think of going backwards sometimes feels like not the right analogy. But your point about what happens in recovery is true. And as we've looked deeper into substance use, right, we can talk about the social determinants of recovery, right? We know that somebody who has a job, a place to live where there's not other drug use being done, someone who can take care of their kids so that they can go to recovery meetings, that all these things make it more likely that somebody's going to get

sober and stay sober. It doesn't mean everybody who gets those things will, and it doesn't mean that people who don't get those things won't, but it just makes it a whole lot more likely and a whole lot easier. And I think the same things you're saying sort of apply to our mental health, right? To embark on a healing journey is to need a certain degree of support, at least early on for a little while. And that support is not just a therapist, right? It is, how do I get back into the workplace so that I can make a living and feel good about myself? How do I have friends who understand me? And I mean, all these elements go into it. So I do think that we need a lot more focus there. I do think it gets a little tricky when these small scale

organizations that seem to work so well on bake sales become bigger and well-funded. Things get a little weird. You know, one of the things that Alcoholics Anonymous did well, now lots of things I think could be different, but was that they remained forever non-professional. They kept a certain element of people putting a dollar in a basket is the way the organization functioned. And that gave it a certain independence and a certain community spirit that I do think is valuable. is valuable. But I don't think everything should be that way. And I think there is somewhere in between those two extremes where we could be spending money much more wisely than we do. It's a great point. It's something I should think a little bit about as well, that part of the effectiveness of a group like AA is simply the fact that it isn't professionalized. It isn't The fact that it isn't professionalized, it isn't commercialized in any way, shape, or form. And so everybody who's there is there for the right reason, essentially.

On this concept of what you need for recovery, I write about that a little bit in the book. And I kind of come around to this idea that was not my own. And I kind of come around to this idea that was not my own. It came to me through John Sherriff, a psychiatrist in Los Angeles, who was saying that recovery is really the three Ps, that you need all three Ps to go on this journey. And he wasn't talking about necessarily recovery from addiction, but any kind of recovery. And Eric, your point about remembering that recovery isn't really going back to where you were. It's more becoming something that you haven't been. His idea was that it was people, place, and purpose that you need social support. You do need a group of people around you who have your back.

And by the way, you have theirs as well. So this sense of community, incredibly important and very, very powerful. It's one of the ways that AA is so effective. You need a place. And that means an environment that's free of all the triggers, but also an environment that is nurturing and allows you to grow and to change. And then I think the third P, which is the one that we never talk about, but is probably in some ways the most critical, is you need a purpose. You need a mission. You need something to wake up for every day, you need something to sacrifice for and to give yourself to, something bigger than you. That third P is almost never in the conversation around healthcare, and yet it is fundamental. I mean, in the book, I go back to this idea from years and years and years ago

of logotherapy, the idea that the person who has a why can live with any how. That's right. That's a really useful mantra, useful concept, but one that you don't hear much about in the traditional healthcare journey. It's just not something that people get to. Right. And there are elements that I think could be better. And I often think there's things that are needed in addition to AA. But one of the things it does well is that it gives you that community, but it also gives you purpose. Because right away, in the right place, you're encouraged that when you have five days sober,

someone who has one day sober is walking in the door. And so you already have something, however small, to offer to that person. You know, that right away you have a purpose, you have value, you can contribute. And for me, it was fundamental. It was really an important part of me that had to get unlocked. And I've just noticed over my life, and I can look back over my whole life, when I've been engaged in doing something that's decent for the world, that's good for the world, that's contributive, I've been well. And when I am not, I have been sick, whether it be depressively, whether it be addictively, whether it be any other sort of variety of behavior problems. But I can look back and I can see it from even being a small child, you know, like when I was in trouble and when I wasn't. And it was all about that purpose.

It's super interesting. I co-founded a company called Humanest, like humanist, but with nest at the end. humanist care around just this principle. It was basically taking the AA approach, putting it online, and allowing people the opportunity to help each other. And it's just been so fascinating to see how that took off, particularly amongst university students. So we have a fair amount of activity at UC Berkeley here in the Bay Area. And asking students where the value of this is, because it's really connected to the counseling center at Berkeley. And the idea was to give students something quickly so they weren't on a long waiting list. And what we found was that the real value wasn't just what students got. It was what they were able to give. That was the most therapeutic part of this. And, you know, it's the piece that, again,

healthcare as we know it, never goes there. It's just not a part of what you get when you go to see your primary care doc. They don't ask you, so who are you helping today? I'm helping you, but who are you helping as part of this? And how do you pass it on? So it's really, I think, a different approach, a different formulation, but a tremendous opportunity to change what we do. And it's all in this kind of spirit of helping people to recover, or at least to be able to function in a way that's, to them, closer to this mental health idea of being able to love and to work. We could all use the occasional nudge, a little wake up from the autopilot we fall into in our day-to-day routine. That's why we send brief text reminders to listeners of the show for free. The texts help you stay on track with what you're learning from the podcast episodes we release on Tuesdays and Fridays. They periodically prompt you to pause for a second and

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and register to win $500, a guest spot on our podcast, or a limited edition signed Jason Bobblehead. It's called Really? No, Really? And you can find it on the iHeartRadio app, on Apple Podcasts, or wherever you get your podcasts. There's been a big emergence in the mental health field around peer support, other people who've been through what you've been through. And as you read about it, one thing that you always hear is the benefit for someone else, but obviously it's the peer who's providing the service who's also getting a lot of the benefit out of it.

But you were initially skeptical of this model because you're a believer that there are evidence-based things that work and then there are other things and that getting the right type of care to people is really important. And that's one of the things AA has the peer piece figured out very well, but there is almost no innovation in what we know more of the modern ideas, more of the evidence-based theories about what works. So I see this sort of, I guess it's a dilemma, maybe it's a matter of balance of, on one hand, there's the peer support model, which provides benefit to both sides of that equation, right? And that there's also very clear interventions that can be done at a professional level that are often very important.

To me, it seems you need a blend of both, but I'm kind of curious what your thought is about that and how you're thinking about the peer movement has changed. Well, it has changed in a variety of ways. I think my concern many, many years ago, when there was a lot of talk about this, maybe 10, 15 years ago, as the peer movement really began to get traction, was I worried that we were going to lose quality. In a field that has so few people providing the care that works, we were going to end up with an army of people even further away from the kind of training that was required. I have to say, I've kind of gone in a couple of different directions with this. One, I think, is that to realize that the real problem we face on the mental health population-wise is not so much on the world of caregivers. It's on the world of what people experience who should and could be in care. And this is true for serious mental illness. It's probably true

for people who have less serious forms. But the reality is that we have good stuff to offer, but only a tiny fraction of people who could and should benefit are getting care. And the reasons for that are not so much that they don't get access. Yeah, there's a bit of that. I mean, there's a supply-demand problem. I get it. I think that's always been true. It's much worse now. But there's another side to it, which is that for a range of reasons, people do not seek care who should. And the problem for me isn't so much access, it's engagement. How do you engage those people that would really benefit so that you get to them

before they're in a crisis, before they're suicidal, before they're in the emergency room, and before you're actually ending up in this kind of medical system, which isn't really incentivized towards helping you in the way that does have the continuity and the recovery focus and all the things we've been talking about. That engagement piece is done by peers better than anybody else. That is where you can begin to solve for the population health problem, the 70% of people or 60% of people who are outside of care. And I think peers have a lot to offer there. I don't think they're the full answer because you still need to be able to get the highest quality interventions, which may require someone who's had 20 years of experience.

And often what happens with peers is as committed as they are and as passionate as they are you know their education is largely an end of one they have their experience and that sometimes is right sometimes it's not right and so there's real value there the other thing we have to be honest about is that asking peers to do some of the heaviest lifting here is also exposing them to a range of triggers that are probably not necessarily in their best interest. And so you have to be mindful of what works, what doesn't. I do think engagement, say it's something that peers do well, I think they're part of a larger army of people. people. That would include community health workers, people who have lived experience in their families, people who may have just been really interested in being in the community and being able to meet people where they are rather than waiting for someone to show up at a clinic.

So I think we need all of that. And if we are going to involve peers in the workforce, and I certainly hope that we do, I think we need to if we're going to be successful. We have to pay them well. We have to professionalize this, and we have to make sure that they're not simply token in some way, or they're not there simply to fill some kind of quota, but that they're given real jobs with real responsibilities and paid accordingly. And I don't see that happening everywhere. All your points there on the peer challenges, I think are really spot on. And I've seen them over the years in recovery from addiction. One being the quality of recovery is wildly disparate, right? Go to five different AA meetings and you may find five very different experiences, which is good in some way if you have access to five, right? And you can

go pick the one that fits for you. But sometimes people don't have the energy to do that. And I do think that N of one thing is also true because this worked for me and I become very fervent about it. When I think of the challenges of 12-step recovery is dogmatism, right? Is that I got sober. So now that old saying, nobody's as zealous as the newly converted, right? So that's good and bad, right? It's good because they've got the energy to devote and really be there. And it's bad because we're only looking at a very small amount of options and there may be other evidence-based treatments that are really good. So I think a blend is really good. You know, an example would be if you're coming into recovery

and you also, let's say, have a serious trauma past, right? To not get quality trauma care is to miss half the game, right? Whereas if you're in recovery, some people might say, you don't need that. Just come to AA. And it's like, well recovery, some people might say, you don't need that. Just come to AA. And it's like, well, for some people, yes, but other people, no. So I think it's a blend, but I think your point is right. Ultimately, my recovery from addiction and depression has taken a combination of peer support and professional support, good professional support. Yeah. Let me just add that, you know, at Human Nest, we had both peers and credential therapists.

And, you know, it's so hard to generalize. I have to say, the peers that we had, I'm no longer actively doing operations in the company, but when I was a couple of years ago during the pandemic, the peers were spectacular. I mean, they were really every bit as good and maybe better in many cases than the credentialed therapists. And I was giving a talk about the need for us to have evidence-based treatments in every part of what we do in the mental health care space. And somebody got up afterwards and said, you know, you've got to remember that the therapist

is as important as the therapy. It really ultimately comes down to having the right person, not necessarily the right brand of therapy. And, you know, he went on to say, you know, that he was a scientist and he'd been looking at this for a long time. And I started to dig into this literature a little bit. It goes all the way back to Healing and Persuasion by Jerome Frank back in the 1960s, because it's so relevant now. But that was Jerome Frank's important insight at a point when people were very focused on the psychoanalysis and doing it in a very precisely technical way, showing that, hey, you know, what really mattered was the person and their relationship that they built. And not so much whether they followed precise rules of how this therapy was supposed to be delivered. There's an important lesson in that, something that we need to remember even today, that it's what you bring to this experience and to this relationship

that's probably as valuable as whatever particular credentialing or whatever particular brand of treatment you've been trained to do. You can go too far in that direction, but you need to keep an open mind that people bring lots of things to the table and not all of it is exactly their training. Right. To be able to say exactly what the exact conditions are that will bring about recovery from a mental illness or an addiction for an individual person. We don't know that. We can see population level data. We can see scientific level data. We can see how many people in this particular thing went this way. But ultimately, it's a deeply individual thing. And what will lead me to get

into recovery might be very different than the person sitting next to me. You know, I might need very by the book CBT that really helps me to work on my thoughts. And that's the thing that unlocks the person next to me might really need a trusted person that they can check in with every week. And that be the most important thing for them. And it's a lot of trial and error. And I think that's partially what's frustrating about mental health recovery and even substance abuse recovery is that ultimately there is a certain amount of trial and error that most people go through before they quite find the right secret sauce that works for them. And that can be frustrating and hard to do often if you're in the midst of a crisis. and hard to do often if you're in the midst of a crisis. But that's been my experience, is that I've had to try a variety of different things and sort of piece some different things together and ultimately find like,

okay, this is the combination of things that really works best for me. Yeah, so that's a challenge. I hear the point, and I think you could have said the same thing about treating an infectious disease 50 years ago, but we've gotten a lot better in knowing how to do that. There's this whole movement called precision psychiatry or precision mental health, which is still maybe a little bit in its infancy, but I think has enormous promise to help get beyond trial and error and to put together different kinds of information in a way

that allows us to get somewhat better. At the end of the day, I still think relationship matters, but at least to get to a point where you're able to say if medication is indicated, which medication, if psychotherapy is indicated, which psychotherapy, and then to understand who can deliver that in a way that works best for you. I don't think that's that far into the future. There are groups doing this now and bringing together multiple predictors. I think the lesson that we have over the last four or five years is that there's no magic bullet.

It's not like genetics or imaging are going to sort of answer those questions. But where the science is right now is it says that if you bring together cognitive testing, EEG, some work on actually accounting for symptoms, and then some sensor data on sleep and on activity and on your patterns, we can begin to triangulate all of that to get an understanding of what might be most helpful on the medical side, to say, oh, you've got a version of depression or PTSD that's going to respond best to X, Y, or Z. And also, in some cases, insight that says, actually, you know what? The kind of depression you have responds far better to this version of psychotherapy than it will to any medication. I think we can do that today for many, many people.

It's not being done. We don't, again, back to your original question, Eric, about the wolves. We're not incentivized to do that. That day is coming. I think there will be a moment when the way in which our field will be reimbursed and supported will require that kind of rigor and that kind of outcome-driven approach that says, you know, if you're a provider, you'll get paid based on how much good you're doing, not on how many hours you're spending.

Can't wait for that day to come or even whatever advances continue to come in that way because like the medication thing, right? That is the frustration of so many people. And most of my experience I'll say is with people who have what I would call a lower grade depression slash anxiety, OCD, you know, it's not what we would call fully disabling, but it's deeply problematic. The medicine thing does feel today very much like trial and error, like try this one. Maybe that sort of helped, but what if I increase the dose? Well, maybe, but so I think that if we can get closer to that, I think that's a really big deal to be able to get a little bit more targeted in those. Now, I want to pivot off of that question

because I think it goes a different direction than I wanted to try and go with you for a second, which is that there seems to be more of a movement that I've been hearing about and detecting that is starting to say that the DSM is not a really useful tool in certain ways. useful tool in certain ways. And that trying to segment these different things apart from each other might be missing an underlying common factor, right? I think there were studies that showed maybe there's a P factor that underlies mental illness. And the people who talk about that say the reason that they come to that conclusion is two things. And I would really love your thoughts on this. One is comorbidity, right? Like if you have depression, you're likely to have anxiety and you're also more likely to have this and that. And you end up with five diagnosis and you kind of go, well, am I really that unfortunate that I got all five of these? That seems unfair,

right? And then heterogeneity, right? Meaning that the way my depression manifests could be different than your depression. You know, mine might cause me not to be able to sleep. Yours might cause you to sleep all the time. And that we're tweezing things apart that maybe aren't as separate as we think. And I would just love to hear your thoughts on that because I've been hearing a lot more of that lately. Yeah, actually, I have to say I haven't thought a lot about this recently. This was a big topic when I was at NIMH a decade ago when DSM-5 was coming out. Very current, apparently. But at that point, we were, as NIMH scientists, we were having to ask the question,

is this really progress? Is this helpful to have yet another diagnostic and statistical manual that essentially reifies these clusters of symptoms when, as you say, they're so heterogeneous and so nonspecific. So just as an example, in that DSM-IV version, you had to get a diagnosis of major depressive disorder. There were nine factors. You had to have five of them for two weeks. So you could imagine two people walking in who had five of the nine, but only overlapped on one. So one out of nine they shared, and yet they had the same label.

I mean, this didn't make a lot of sense. Furthermore, you'd see the same person over time. And it would be, as you say, every time you'd see them, it'd be a slightly different pattern. And so you just had the sense that, as somebody said to me, we weren't cutting nature at the joints. It wasn't really capturing the fundamentals. We started a project that was then called the Research Domain Criteria Project, RDoC. Very controversial at the time. But we basically said, look, for research, DSM isn't working. And the reason it's not working is because we're funding people to do biomarkers of depression. And they go out and they measure

something in spinal fluid or blood, or they do a brain scan and everybody with major depressant disorder as defined by DSM and they only see the finding at 50%. So they decide it's not useful. And our response was to say, nonsense. Maybe you start there on everybody who has the same brain scan and you work from there instead of throwing that away and saying, oh, it has to obey exactly what the APA suggests is ground truth. We just didn't think anybody had really established ground truth. So to do that, what we were asking the research community to do was to not use DSM, except in a kind of distal way, but really to begin to collect the data about large numbers of individuals to see where the different factors would aggregate. So if you took everybody,

you know, with some frontal temporal disconnection syndrome on their fMRI, does that give you something you can work with? A lot of this was really borrowing from what we were learning on precision medicine in cancer. You know, previously, cancer diagnosis had been based on gross pathology, and you grouped everybody together based on that. And then you discovered when we got into genetics that, wow, that didn't work at all, that what really mattered was identifying the molecular lesion, because that would determine who would respond to which treatment. And you'd find the same molecular lesion in tumors that look grossly very, very different. So we began to realize in cancer diagnosis that, wow, we can't really use just the observations.

We have to have genetics. In mental health, genetics itself doesn't really seem to work that well. It might work for autism, but it doesn't seem to work so much in current areas that we look at. There just aren't kind of specific lesions the way you have them in cancer. But there are other things we can begin to use. And I mentioned them before, you know, approaches like EEG and cognitive testing. And I think there's a lot we can do just to understand behavior better, beginning to look not only at sleep, where you actually measure sleep, but looking at activity and looking at voice and speech

and how all those things are changing. We can begin to provide much more objective data about mood and anxiety and cognition and psychosis. I mean, all of that we can do far more precisely than what we've been doing. And with that, I think we can start to rebuild how we think about the labels that we need in this field. A really interesting set of studies by a guy at Harvard, John Weiss, who I think is worth reading. I talk about him in my book. And John is just focusing on children in particular. And he sort of just does away with all these diagnostic things. It says, look, there are just really

five things in kids that you want to be able to understand in terms of dimensions of behavior. And each of them has its own intervention that you need. When I read that, it all became just much simpler. I actually think that probably where we need to go is not, we're now what, at 350 or something like that, 360 labels in DSM. Maybe we need 10. Maybe we need five. I don't know. But I think what John Weiss has done for kids is actually a very interesting project that something like that might help to inform what we do more broadly in adults. I think RDoC itself was an interesting way of sort of trying to turn the herd, trying to move the research community in a different direction. It was never meant to be a clinical tool, but the hope was that it would begin to inform

whatever DSM-6 becomes. And we'll have to see whether that happens. I do think, to go back to your original question, Eric, is we have to do a better job of thinking about what's diagnosis for and how do we use it? Because at this point, you know, what really counts, I think, is treatment. It's interventions. And it's not helping us in choosing interventions for the most part. And I think that was really the problem with our doc. It was never really tied to treatment response. It wasn't intended for that. But ultimately, you want to be in a world

where you are collecting information about how people think, how they feel, how they behave, and using that to provide interventions that help them to get from where they are to where they want to be. We haven't done that. I don't think DSM does that. I don't think RDoC has yet done that. And I think we have to get maybe much simpler if we want to be able to accomplish that. But I'm not sure I know how to do that yet. I'm Jason Alexander. And I'm Peter Tilden. And together on the Really No Really podcast,

our mission is to get the true answers to life's baffling questions like why they refuse to make the bathroom door go all the way to the floor. We got the answer. Will space junk block your cell signal? The astronaut who almost way to the floor? We got the answer. Will space junk block your cell signal? The astronaut who almost drowned during a spacewalk gives us the answer. We talk with the scientist who figured out if your dog truly loves you and the one bringing back the woolly mammoth. Plus, does Tom Cruise really do his own stunts? His stuntman reveals the answer. And you never know who's going to drop by. Mr. Brian Cranston is with us today. How are you, too?

Hello, my friend. Wayne Knight about Jurassic Park. Wayne Knight, welcome to Really, No Really, sir. Bless you all. Hello, Newman. And you never know when Howie Mandel might just stop by to talk about judging. Really? That's the opening?

Really, No Really. Yeah, Really. No Really. Go to reallynoreally.com. And register to win $500, a guest spot on our podcast, or a limited edition signed Jason bobblehead. It's called Really No Really, and you can find it on the iHeartRadio app, on Apple Podcasts, or wherever you get your podcasts. Thank you for that, because I've heard RDoC often quoted, when they come to this conclusion, they talk about, well, even NIMH came to that conclusion.

So your background on that, how it was really intended for research is really helpful. Because it sounds like on one hand, we're sort of saying almost two things. And I want to get a little clarification. On one hand, we're talking about getting far more precise and specific in precision medicine. We're actually going even deeper than these you know, these different clusters of syndromes and we're really narrowing into Eric, right? What's going on with Eric, right? And at the same time, we're also talking about maybe simplifying some of the overall models so that they make more sense with what's happening. So it sort of sounds like in your mind, it's sort

of both, right? It's let's get simpler in certain ways, but in other ways, we're actually saying, let's get even more specific. Let's go beyond going from, let's say there's 500 diagnoses in DSM and instead of going to 750 diagnoses, right? We actually go to Eric and we're precise enough to say, we don't even necessarily have to give it a name, but we know based on what's going on with Eric, here are the interventions that we think are going to be most likely to be helpful. Is that an accurate way of saying it? but at least in lung and breast and many solid tumors. We've gotten very, very good at being able to say what we thought was one disease is 20 different diseases and each of those 20 require a different treatment. And you're finally, based on that, beginning to bend the curve for mortality and morbidity from cancer.

Pretty darn cool. We don't know how to do that yet for depression or anxiety disorders or psychotic disorders. But my goodness, as you said before, Eric, I mean, they're incredibly heterogeneous. At the end of the day, what you really care about is what can we do for one person at a time? What really makes sense? And so I would agree with you. We want to both make it simpler, but we also want to make it very individual. And understanding how to do that will be important. We also want to kind of empower people to help themselves in ways that we haven't had. And I think that in some ways is very different than

the cancer model. So the cancer model really comes out of the medical approach that if we can just get smart enough, our experts will figure this out. What I want to suggest here is this is not the same. It's a different set of problems and that people place in purpose, creating community, creating environments, creating purpose, which is really the essence of what we're going to need for recovery. There is no single magic bullet. There's not going to be a genetic finding that gets you there. It really requires a different way of thinking about the problem and a different orientation to solutions. You know, solutions that are much more social than medical. And I'm not sure we've quite grasped that as a field. And that's not to say, I mean,

I often try to get away from these dichotomies. And the way I've tried to resolve this one, and I struggle with this in the book, and I kind of finally end up this way is to say, I think that we can define the problem as medical, but the solutions are going to be social, environmental, even political. I wouldn't say that about breast cancer or hypertension. I think there, you know, the problem is medical and the solutions are mostly coming up with the right medical intervention. Here, I think the problem can be defined as medical. I think there's, you know, fundamentally, particularly for people with serious mental illness, you're talking about something in the brain or people with addiction. It's now a brain disorder.

We're talking about something in the brain or people with addiction. It's now a brain disorder. But those solutions are going to require something very different than what we do in the rest of medicine. I think it's a particular challenge for us to figure out how do we do that? Who does that? How do we pay for that? How do we make it happen? And that's where I think the book kind of goes into asking for a radical rethinking and actually a new social movement, kind of like a civil rights movement to say, we're in the Jim Crow era here that people with serious mental

illness end up incarcerated or homeless instead of in treatment. And the treatments that they get when they do get treatment is so coercive and so ineffective. We have good stuff to offer. They don't get it. How do we turn that around? And how do we make sure that those 14 or so million people who currently are mostly found in the criminal justice system are, to use President Kennedy's original comment about this in 1963, when he said, they must no longer be alien to our affections. That's our challenge, is figuring out how to make sure that this group of people who have become so disaffected and so disenfranchised by us, to be really clear, they're really marginalized, how do we take them into our hearts

and start to provide people place and purpose to allow them to recover? That's, to me, a massive social movement that needs to be undertaken and needs to happen yesterday. Yeah, I think that that's one of the things that's often been confusing for people around thinking of alcoholism. It was called a disease for a while, right? And that got confusing because the primary treatment for people was for a long time and still to a large extent today, you know, when I said AA hadn't become professionalized, that's not entirely true. AA has remained unprofessionalized, but an entire infrastructure that uses 12-step as its method of recovery has become professionalized all around it.

But when you look at it, one of the things that becomes difficult is to say, well, I've got a disease. We're saying there's a medical component, but the thing you're giving me to do looks somewhere between moral, spiritual, community. Those two things feel like they don't quite line up. And I think that makes it a more confusing thing. And I think we're talking about the same thing here. Now, I also think with SMI, it's important that we should mention we've been talking about the three Ps, but in no way, shape or form, are you saying that medicine and the psychiatric drugs that we have, they have a place and they have a purpose and they can really be beneficial. So we're not saying the three Ps at the exclusion of those. I just want to clarify that. What you're saying is we may be delivering some of the medicines well enough, but probably not. But on top of it, we also need to be looking at this other element. When those things are delivered, they're delivered very fragmented from each other. You might get one or not the other. You might not get either. But they're not coming together into a coherent treatment plan. You got it. You said it better than I would have, Eric. I mean, the issue is that this is not

instead of, it's in addition to. And I don't really fully understand this, that this field, this mental health field has become so polarized. It's either medical or it's recovery. It's either getting medication or you're getting psychotherapy. Who benefits from that polarization? Why do we tolerate this? We wouldn't tolerate it for most other human problems. You want people to get access to as many things as possible. And I think some of it comes about because it's more about us as providers than it is about the people who we should be trying to serve. And if you see it from the consumer's point of view, it's like, what's best for me? And it's often not one thing. It's a combination

of things. And very often, that's just not possible to do. They end up with a primary care doc who's going to write them a prescription for an SSRI, or they end up in psychotherapy with a social worker who's going to spend a lot of time exploring their past trauma. It just feels to me like someone needs to knock down that divide so that you get access to both when you need it. I couldn't agree more. And, you know, we get lots of requests for guests on the show and there are all sorts of people who will fall on either of those extremes and what they want to promote. And I'm just not interested in promoting that, you know, like, are there problems with big pharma and our use of psychiatric drugs? Of course there are, but that doesn't mean that they're not enormously helpful to so many people. You know,

for me, my recovery has been, I often say my recovery from depression has been by throwing the kitchen sink at it. Medicine has been a part of that. Exercise is a part of that. Sleep is a part of that. My community is a part of that. For me, it's been like, let me bring it all to the table. And which is more valuable than the other? I couldn't begin to tell you at this point because they've become so intermixed over the years. But I wouldn't want to try without one of them. I wouldn't like to just jettison one of them and be like, well, let's see what happens. You know, I found something that works for me. And I do think

that this polarization is not helpful because it leads people to either only depend on medicine or not take medicine at all. And the answer is far more nuanced. We just don't happen to be a culture that's very into nuanced conversation. Yeah, I think that's right. I guess the message I'd want listeners to take on this though, is is that, believe it or not, most people ultimately find something helpful because there's a lot out there to choose from. And whether that's medication or therapy or the social support networks like AA, you know, in a church basement or humanist online. I mean, they're just a range of things that people can engage with. And we, you know, one of the things that's happened during the pandemic is we now have literally hundreds of different online services, some of which are very

good and are trying to do kind of what AA does, but doing it in a way that's far more convenient. I think there are plenty of opportunities to get help in a way that works for you. And that's the great thing now is you don't necessarily have to wait three and a half months on a waiting list to see a therapist. You can probably find someone or you can choose amongst thousands of people who would be available online through one of the current therapy or medication companies. I think that's a really important message of hope and a message of to continue to seek help. You know, one of AA's key lines is keep coming back, right? And to me, that actually should be broader than AA, right? But it just means there is hope, there is help. Keep investigating, keep trying, which can get discouraging, but is really important. I want to hit one last idea with you, then wrap up. You talk about something you call

the pro dome, meaning that before somebody develops severe psychosis, right, there's often a multi-year period where behavior is beginning to change. There are things we know to look for and that early intervention makes a lot of sense. Now, I think this is common sense. Maybe it's not common sense. Maybe it is just to me. I think that's a really important point. My question is more around similar to alcoholism or addiction, and this is starting to change a little bit, but things have to get to a certain level of bad before people are willing to do a whole lot about it. So do you have any insight into how to get people to help sooner before it becomes a crisis? Any thoughts on that? A lot of thoughts on the mental health side.

So we know a lot about it. And NIMH was deep into this area of science, trying to understand for those, maybe there are 100,000 young adults who will have first psychotic break, first episode of psychosis this year in the United States, usually between about ages 15 and 25. That's kind of the vulnerable years. And as people have looked at that, they began to realize that, in fact, there were a lot of warning signs, sometimes going back two or three years. That's this prodrome idea, as opposed to the syndrome. This is before there's a syndrome is the prodrome.

Okay. And the concept was, if we can detect that, like pre-diabetes, could we treat it and actually prevent the psychotic episode? And so a lot of energy has gone into this. It turns out to be harder than you think. And so a lot of energy has gone into this. It turns out to be harder than you think. So many people between the ages of 15 and 25, or if you go three years earlier, between the ages of 12 and 22, you know, they're experiencing a lot of emotional chaos. That is what adolescence is all about.

So knowing which one of those people will go on to hearing voices and becoming delusional. It's hard, really, to predict. We're learning more, and the thought had been that, well, maybe there'll be some biological factor that'll help us predict. And there are some pretty good signs. I think the science there is interesting, but none of it is scales to allow you to do this for a whole population. So we're still, I'd say, trying to figure this out. Whether you could do the same thing for, you know, when does social drinking become alcoholism?

When does the use of any addictive compound begin to become a problem? I'm not sure we've thought as well about that. And it may have to do more with not what you use but how you use it and whether as you know my colleague at night i used to say when it goes from being something that you like to something that you need that's really the transition and that happens in various ways it's so interesting to me that it's not a function of how much somebody uses the substance, but how that substance uses them and how it changes what they do. And that dependence is really often dictated by lots of things that are not just about the pharmacology of the compound or the biology of the person, but other factors. Yeah. Yeah. And I think there is a

difference between those two in that, you know, addicts are using their substance because they're getting a lot out of it. Right. I mean, make no mistake. There's a period of time where it feels like a positive experience. Right. And so it's harder to give up because you're still getting something. Whereas, you know, a lot of these sort of emotional or mental disorders, you may be able to have more success intervening earlier because it doesn't tend to be pleasant. Yeah, I think that's certainly true for this protro thing. But almost no one gets help for that. And the fact is, we're not even sure

what is the right intervention. There have been lots of attempts to find that it's probably going to be a cognitive intervention, but helping people with working memory, helping them with focus, helping them if they have ADHD at the same time to get that under control. I don't know. I do think that one of the lessons generally is that the earlier you can detect and the earlier you can intervene, the better the outcomes. And that just seems to be a fundamental truth across all disorders in medicine. No less true here.

But we're not very good at that. We tend to get involved in the late innings when we're already a few runs behind. It's really hard to win the game under those circumstances. Well, I think that we can end with the hope that there are treatments and the idea that early intervention is better. Tom, thank you so much for coming on. I feel like I could ask you a hundred more questions, but you probably have a few other things to do today. So thank you so much. I really enjoyed the book. I really enjoyed talking with you and thank you for all the great work you're doing in this field. Eric, it's a pleasure. Thanks for having me.

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