Today, Explained - This country is a lot right now

Episode Date: June 30, 2022

The past week/month/year/pandemic has taken a toll on a lot of people’s mental health. And the US has proven woefully incapable of dealing with mental health for years. This episode was produced by Haleema Shah, edited by Matt Collette, fact-checked by Tori Dominguez, engineered by Efim Shapiro, and hosted by Noel King. Transcript at vox.com/todayexplained Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

It's been a week. When I went in, he shut the door. I noticed Bobby Engel, who is the head of Mr. Trump's security detail, sitting in a chair, looking somewhat discombobulated and a little lost. Never met Bobby Engel. Can relate, though. We are living in worrisome times. The economy, the guns, the pandemic, the war, the ex-president grabbed the steering wheel, allegedly. It's affecting us. We are discombobulated and a little lost.

Also anxious, depressed, not sleeping, and not doing so well addressing it. The National Institute of Mental Health says one in five Americans suffers from a mental illness. Coming up on today explained the doctor once known as the country's psychiatrist on what we are getting so wrong about mental health and how to fix it. Get groceries delivered across the GTA from Real Canadian Superstore with PC Express. Shop online for super prices and super savings. Try it today and get up to $75 in PC Optimum Points. Visit superstore.ca to get started. It's Today Explained. I'm Noelle King. There is a difference between anxiety and worry and discombobulation and what's called an SMI or a serious mental illness. So maybe during the

pandemic, you realized it was too much and you needed a therapist, and maybe it was hard to find. But if you have an SMI, you've known that for a long time, because you've likely been dealing with our broken system for years. Right before Basi Iqbi found herself navigating that system, she was at a high point in her career. She'd landed a spot on HBO's Deaf Poetry Jam. I fear that you will never sleep, that like these fingers long and too thin to hold wings or commitments, you will inherit your mother's insomnia. Energy, creativity, and talent drove Basi Iqpi. Also, the insomnia. I still think you deserve more than this threat of me

as your mother, still attempting her own world of colored things. But child, just promise me that you will be eventually. I need your possibility like I need a night worth sleeping for. Her insomnia was part of a mental illness, and she'd spent years navigating a health care system that even doctors say is profoundly broken. Baziakby had these fixes for when things got dicey with her mind. One thing that I realized is that I had figured out ways to make the way my brain works work for me, meaning that when I had the energy, I would kind of disappear, not go out as much and use that time to just get my energy back. And I was able to do that because I wasn't in school. I was an artist. I didn't have a set schedule. But the fixes were temporary. I was on tour with Deaf Poetry Jam. And when I was on tour, no matter what, I had to be backstage by 7 p.m.

and I had to be on stage by 8 and I had to be awake at X hour for rehearsal or to get on a plane or to get on a bus to get to the next city. And I wasn't able to set my schedule around my moods, and I realized these coping mechanisms were completely impossible on tour. And I started getting really withdrawn, and I stopped eating, stopped sleeping, and I just stopped talking to everyone. And a lot of them were like, okay, so, you know, the fame is getting to her, you know, stuff like that. And I didn't know what was going on. I just know that this way that I usually feel for a couple of weeks, couple of months was just sort of here. And I couldn't pretend myself out of it.

One night in Chicago, I couldn't stop crying. I was getting myself up off the hotel floor, and I walked out of the hotel to get to the theater, and I didn't have a coat on, and it was freezing winter in Chicago, January in Chicago. I get backstage, and I'm trying to give myself this pep talk. You can do this.

Just wash your face. Put your makeup on. Put your costume on. You're going to be great. You're going to be fine. And I just couldn't stop crying. And I somehow ended up underneath the sink in my dressing room in the fetal position, just bawling my eyes out, just crying. And the stage manager, Alice, came into my dressing room. She literally crawled underneath the sink with me and like held me. And she said, if you don't get help, you're going to die. I had never thought of it in those terms, but I immediately knew what that meant.

When she was 27, she got her first diagnosis, bipolar 2 disorder. Had no idea what it was. Never heard of it. I knew I wasn't bipolar because I knew what bipolar was and that that wasn't me. And I remember telling him, I can't have that because I'm Black. I was like, I've never heard of it, and I've never heard of any Black person with it, so it's something else. What was your understanding of what bipolar was that made you so sure you didn't have it?

It was people who were crazy. They were, you know, found walking the street naked and all these stereotypical iterations of what a crazy person was like. Because when I was diagnosed, I didn't tell my parents for another five or six months. And remember my father going and doing research and looking at the symptoms and he could, he could identify each symptom from me growing up. And I remember him feeling so guilty about not being able to do anything. And I was like, dad, you don't know what you don't know. There's no way for you to have spotted that because no one understood who I was or what I was going through. And me dropping out of college and suddenly moving to New York, all that stuff made sense to him,

but it didn't make sense to him at the time. And my mother took it much harder. She, I think, was very afraid of what it would mean for the rest of my life and how people would treat me and what it would mean for people to know. She was very adamant that I don't tell anybody about it. But I see that that came from fear. Can you walk me through what the treatment was like when you first got that diagnosis? You know, I was able to call Dr. Goodman and say, this one isn't working. It makes me feel this. And he would talk to me, like I'd call him on like Thanksgiving and he would take my call and he would walk me through. And I just felt like I felt cared for. And that

definitely helps the way that I approached my own illness. And I think that had I run into doctors that treated me more like a statistic or made me feel more like just somebody on a conveyor belt and they would forget me as soon as I walked out the door. It would have been much more difficult to accept my diagnosis and it would have been a lot more difficult to accept my life afterwards. Bussie, out of genuine curiosity, what kind of insurance did you have? At that time, I had whatever the theater actor's insurance was. That's how I got them. But because I wasn't working, I lost that insurance. And all the money that I made on tour, I started paying them out of pocket.

And I, of course, ran out of money. And I had to make a decision between therapy and medication. And I hated medication. So I chose therapy and stopped taking my medication. And I ended up in the hospital November of 2004. And then I stopped taking medication and stopped going to therapy for years. A really good friend of mine died of cancer. And I wanted to, I just wanted to feel it. I didn't want to feel like medication was making me take it well. I didn't want to take it well. That started a spiral

that lasted from 2005 to 2010 when I was hospitalized for the second time. Now I'm back in Maryland, you know, living with my family. And I currently have Maryland Medicaid, but Maryland Medicaid, it's great. I've never felt as though I wasn't getting good help or good treatment or medical care because of it. And part of the reason why we stayed in Maryland instead of going back to New York was because the health care system here, the state health care system here is much better than it is anywhere else in the country, I believe. I'm the healthiest I've ever been in my life. 2017 was my last serious depressive episode. One of my greatest victories is that about a year ago, I got a credit card.

For the first time in, like, I want to say 20 years, because I would just use them constantly. I'm very irresponsible and reckless when it comes to money. And being able to get one and to have one and to use it in a way that normal people quote-unquote would use it that's been huge for me the victories are the things that kind of keep me going because I want more of them so much of mental health is focused on the illness and not what happens during treatment and what happens after treatment and I think that's more important to know what it looks like to live with, as opposed to constantly being reminded what it is to suffer from. Bazzi knows she's lucky that she got the care she needed to treat her mental illness. Why do so many people not?

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One evening in May 2015, Dr. Thomas Insel was in Portland, Oregon, giving a presentation to a room full of mental health advocates. He's a neuroscientist and a psychiatrist, and for 13 years he was the country's psychiatrist. That's what people sometimes call the director of the National Institute of Mental Health. Anyway, he's presenting to this group, and... One of the parents got up and said,

you know, you just don't get it. I have a 23-year-old son with schizophrenia, and he's been hospitalized five times. He's been incarcerated three times, made two suicide attempts. He's currently homeless. Our house is on fire, and you're talking to us about the chemistry of the paint. I was defensive. I mean, at first I thought, well, you know, it takes a long time. Research is a marathon. It's not a sprint.

And we need to know much more before we can do much better. But I also recognized that he was speaking for a lot of people who had that same feeling that this wasn't just a science problem. This was an urgent public health crisis that didn't just require that we know more, but that we do better with what we know right now. And that urgency is not the way we do science generally. At Dr. Insull's direction, the NIMH and its billions of dollars in government funding had pivoted to focus less on behavioral research

and more on genetic research into what causes illnesses like schizophrenia and bipolar disorder. And they made some stunning scientific advances while looking into genes. The problem was, Dr. Inssel started to realize

those advances weren't doing very much at all for patients. Science was looking for causes. Millions of people, he says, were suffering the effects. 17 years ago, the federal government established a research project with the ambitious goal of mapping the entire human genome. When I arrived at NIH in 2002, the big breakthrough was the completion of the Human Genome Project about six months later. Genetic mapping researchers know more than ever about the hereditary influences behind cancer and heart disease and diabetes and many other

conditions. Every area was looking at that new map we had of the human genome and saying, how can we use that to understand not only the inheritance and the biology, but the opportunity to identify new targets for treatment. The scope and long-term potential of the Human Genome Project has been compared to the Apollo Project. Sometimes that works really well. And in the case of autism, I think we were able to find a range of new targets, some of which are now leading to new treatments. maybe highly heritable or bipolar illness, which is more heritable than hypertension or diabetes,

is that we found lots of signals, but no kind of, no treatment targets. The signals we found were signals about risk. And there were so many of them, actually, rather than finding just a few. We found so many, each of which contributed a very small amount. So was that a mistake to go after that? Well, of course not. The whole nature of science, the reason we call it research, is we don't know what we're going to find. In this case, we found lots of stuff, but we didn't find what we were looking for, which was the kind of high-profile, high-impact molecular target that could be used for a new class of treatments. And one of the points I make in writing the book is, we've got pretty good treatments right now. For me, the egregious piece of this is not that we don't have anything to offer. It's got plenty of

stuff to offer. We're just not doing it. And so again, this is not an NIMH problem. This is a problem of a health system that's badly broken. I think many Americans would agree with you that getting health care feels like a maze. But psychiatry is also, as you know, a nascent field. Just a couple decades ago, people would be treated with lobotomies. How far have we come in providing therapies that are safe and effective? We've come very far. We have medications that show efficacy, that they have a statistically significant effect in a randomized clinical trial. And that's been established

for over 20-some antidepressants and for multiple antipsychotics. We also have pretty good data on safety. The difference, though, between efficacy and effectiveness is what these medications do in the real world. If people don't take them, they may be efficacious, but they're not effective. And that's often the case with these medicines where, in some cases, in some studies, 50% of people stop their medication before it's shown its full value. Why? Why do people stop taking their medication? Two main reasons. One is because the medicine works and the symptoms go away. So why wouldn't you stop it? And we have a model that tends to think that this is just about treating symptoms.

And so you don't need it if you don't have the symptoms. The second is that almost all the medications in psychiatry have side effects that people don't like. They're not, you know, we've traded one set of side effects for another. A lot of people have that sense of brain fog or they're sedated or they gain weight or they have sexual side effects. And, you know, nobody wants that. So it's often this very awkward balance between finding something that works and something that doesn't have a side effect that makes you feel worse. And those are tough decisions to make. And there's a lot of trial and error and stop this one, start that one, change the dose, put two medicines together.

The point I've tried to make in the book is that when we talk about treatment for these illnesses, we need to start talking about more than medication. We have psychological treatments. We have other treatments that are really quite important and can be effective and also safe. And there's no reason not to combine them. So optimal care would involve both medication and psychological treatment. Recovery is something very different. It's helping people to really build a life. And I can't stress how significant this is for people with serious mental illness. And the recovery model, as I talk about, requires the three Ps.

That is people, place, and purpose. These aren't covered by insurance. There's no pill for this, but social support, having a sanctuary where you can recover, where you can heal, and then having a reason to recover, having a purpose, having a mission. Incredibly important for young people who have a mental illness to feel like they have a purpose as well. And our healthcare system rarely engages on those three Ps or understands the importance of doing so much more than just pushing another medication. I'm wondering, in an ideal world, this gentleman who has a son who's struggling with schizophrenia and ricocheting between hospitalization and homelessness and incarceration,

what kind of outcome in an ideal world, in what it sounds like you're saying is potentially a buildable world, what kind of outcome does that lead to for him? It's a year, potentially multi-year commitment to making sure that he gets decent health care, that he has a decent place to live, that he's getting not just medication, but he has to be on medication most of the time. Most individuals are going to need that. But much more comprehensive, what we call whole person care that deals with a range of issues, some of which may be cognitive, some of which may have to do with the fact that he needs job training or he needs an education to be able to get the skills that will allow him not to be unemployed and disabled.

I have sent to the Congress today a series of proposals to help fight mental illness and mental retardation. The United States really took on this problem in the early 1960s under President Kennedy, who in the last act that he signed, the Community Mental Health Act, on October 31st of 1963, before he was assassinated in November. With respect to mental illness, our chief aim is to get people out of state custodial institutions and back into their communities and homes without hardship or danger. He said when he signed the act, he said, you know, folks with mental illness should no longer be alien to our affections or separated from our communities.

It will be possible within a decade or two to reduce the number of patients now under custodial care by 50% or more. That didn't happen for a lot of reasons, although it started to. But what's interesting is we're back at it again. And over the last two or three years, for the first time really since the 60s and 70s,

the federal government is creating these comprehensive community centers. This unassuming building in the South Bronx is what's known as a clubhouse. Its members have severe mental illness. Who have really hit what we'd call stage four of mental illness when they are truly disabled and have been homeless and incarcerated and really not functioning. It was three years ago when Denise Velez arrived. She says homeless and in a deep depression. Because of them helping me with the job and everything, I was able to find my self-worth and my courage and my will to get back out there, get back to work, because I felt worthless. Giving them a place where they can recover between having clubhouses and then having these clinics that are in the community that have no wrong door, that are able to follow people for periods of time and to ensure that they're getting optimal medical care,

they're getting the kinds of supports for this kind of whole person care approach that they need. I take a couple of classes each day. This semester I'm focusing predominantly on my socialization skills by both taking classes where I get to practice both speaking and listening to others. That's beginning to happen, and it's really, to me, it's a very hopeful sign that we have both the national and, in many states, the state leadership to make sure that people with these illnesses are no longer alien to our affections or apart from our communities. Dr. Thomas Insel's new book is called Healing, Our Path from Mental Illness to Mental Health.

Bazi Ikbi has a book out too. It's called I'm Telling the Truth, But I'm Lying. Today's show was produced by Halima Shah, edited by Matthew Collette, engineered by Efim Shapiro, and fact-checked by Tori Dominguez. I'm Noelle King. It's Today Explained. Thank you.