While serving as Director of the National Institute of Mental Health from 2002-2015, Tom Insel, MD witnessed a troubling conundrum: The agency was making substantive progress in science and mental health research yet that work was not having enough impact on the public’s health. Instead, rates of suicide, homelessness, incarceration, overdoses and mortality were all rising significantly.
Now, Insel has written a new book, Healing: Our path from mental illness to mental health, that draws on that experience as well as his subsequent role at Google. Healing follows Insel’s previous books, The neurobiology of parental behavior and The psychobiology of obsessive-compulsive disorder.
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Leading up to the 2022 Summit, where Insel will be among the Main Stage discussion leaders, Health Evolution Editor-in-Chief Tom Sullivan spoke with Insel about the book, trying to accomplish something similar for mental health to what former Vice President Al Gore did for climate change, why it will take a social movement to fix U.S. mental health, and more.
What inspired you to write Healing?
Insel: It wasn’t inspiration. It was confusion. I wrote it because I couldn’t figure out something that was really nagging at me. Fundamentally, I had been in the world of academic research, at the National Institute of Mental Health as Director, and I loved it. I was blown away by the progress we were making in so many areas, genomics, neuroscience, cognitive science especially. The world was being transformed by science. I was there from 2002 to 2015. During that period, I had a chance to see what seemed like the Golden Era for science and mental health research. At the same time, the suicide rate went up 33 percent, the homelessness rate went up probably two- or three-fold, overdose deaths went up in those years by 300 percent. What really struck me was the conundrum that with so much progress on the scientific side and the fact that we were learning so much and doing so much better — and we had at this point, pretty good diagnostic tests and really good therapies — yet on the public health side the numbers were going in all the wrong directions. Morbidity and mortality were getting worse, not better, more people were incarcerated, more people were homeless. The conundrum for me was: Why in the real world of care are we failing when in the world that I was living in we were succeeding brilliantly? And how do we square that? How do we connect those dots? That’s what got me started. I had to figure this out because I don’t want to continue doing what’s not working.
And what did you determine? For CEOs developing mental health strategies with an eye toward the future, what is the path forward, if you will?
Insel: Because I had moved from government to Google — and the reason I did it was recognizing we had this gap and I thought ‘go where the people are, use the power of big data and deep pockets’ — the first thought I had was that we can actually get this done. But it’s not that simple. So, I spent three or four years trying to figure out how we fix the broken care system. That part of the conundrum was that even though we have good treatments, people don’t get them and they don’t get them for many reasons. But a big reason is that we have a care system that is really a sick care system, not a health care system. It’s incentivizing providers and patients and families in all the wrong ways. What ends up happening is people avoid care, they get into care only when they’re in a crisis. Crisis care often leads them into jail or into prison instead of into our health care system. And when they do get into the health care system, it’s highly fragmented. It doesn’t provide continuity and they don’t have a feeling of agency or of any control over what’s going on. They don’t like what they find. More than half of the people who should be in care are not in care because they don’t want what we have to offer. They don’t buy what we’re selling, basically. In mental health care, the people who need care the most often don’t get it, or are the least likely to engage in it. You don’t see that as much for cancer or heart disease, but in mental health, when you’re really, really sick, you don’t think you’re sick. You end up more likely to be in jail or prison than in the health care system. That’s not a great recipe for good outcomes.
So that was the beginning. Much of the book was about the broken mental health care system and how to fix it. It took me a long time to begin to understand that we could really do a lot to fix the system and make it much, much better — but we still might not be able to solve the conundrum that started me on this whole journey.
If we can improve the system but not necessarily solve the conundrum, what’s the solution? Or, at the very least, what’s next?
Insel: When I went to places that did better at mental health care, we still saw a lot of the same problems. In New York and efforts underway in California and many places, we were spending a lot of money, involving a lot of people and training a lot of people but the outcomes weren’t getting that much better. That’s when I began to realize that I had been thinking about the problem in the wrong way and that the problem wasn’t just that we had a broken care system. We did, and we do have to fix that. But if I was really honest with myself and I really wanted to focus on improving mental health in America, it’s not just about us. It’s not just about health care. It’s about a lot of other stuff that isn’t yet part of health care: having what I call the three Ps of recovery: people, place and purpose. That’s really the model. Reducing symptoms in the moment is important, but insufficient. What we really need to do if we want to begin to solve the conundrum and to actually do something about the rates of incarceration, homelessness and chronic disability is to engage those three Ps. Whether we do that in health care, or we do that through the social safety net, it must be what we commit to if we’re going to bend the curve here.
The author Michael Pollan is quoted as saying that your book should become a call to action for a new social movement. Was igniting such a movement one of the reasons you wrote the book?
Insel: When I started writing this book, it was to figure out the conundrum but by the time I finished the book, I was convinced that what we needed wasn’t just more collaborative care or more precision medicine — all of which are important and we do need those — and what we need is a social movement for the mental health crisis. We need what Al Gore did for the climate crisis and that’s what the book is. It’s really an ‘Inconvenient Truth’ here just to call attention to what is a national problem here in the U.S. We are exceptional in how poorly we are dealing with the mental health crisis. Even before COVID that was true, but it’s doubled down with the effects of COVID. There’s no magic bullet for this. It’s going to require broad engagement. It’s going to require broad understanding of the complex problem and it’s going to require more than just more clinics and more pills and a bigger workforce. It’s going to require understanding that this is a problem that involves all of us. It’s not just the people who are homeless that we’re walking over, stepping over on the street, or the people who are currently incarcerated. They’re sort of the canaries in the coal mine.
Fundamentally, the point of a social movement is widespread recognition that we are going to have to take a much more comprehensive view of this problem. We’re going to have to think about rebuilding the social safety net that we’ve allowed to become shredded in America. We’re going to have to think about things that we don’t usually think about as health care systems or health care providers, such as family support, parental leave, pre-K support, the fact that kids who do go to college graduate with so much debt that they end up getting buried in that and the amount of stress they feel. We need to be thinking at that scale and at that level.
One of the pressing challenges that pre-dates the pandemic but has come to the fore is the need to integrate mental and behavioral health with physical health. Is there a point on the horizon where you can envision that integration actually being widespread?
Insel: We’re in this extraordinary moment of real transformation for the way mental health care is provided. One of the silver linings of the pandemic is that mental health care has had to reinvent itself. I don’t think we’re all the way through that. Instead, I like to think of it as a five act play and we’re in act one still. But we do have in place an enormous number of new companies that are providing telehealth that can be convenient and can be done in a way that integrates with primary care. The integration is an act two problem to solve because it’s still often a carve-out for people. Some of this is paid for with insurance, some of it is paid for out-of-pocket, but it’s an improvement from where we were. The integration of specialty mental health care with primary care has been more difficult than it should have been. I’ll add into that the integration of substance use disorder or addiction care. Even integrating that with mental health care has been a challenge because we have this very fragmented system. We have a model for collaborative care and we’ve known for 25 years that it’s highly effective at delivering better outcomes at lower costs yet it’s been very difficult to implement. But that’s a solvable problem because the model does work in figuring out ways to improve the scalability of collaborative care. It’s critical to know that most mental health care today, like most medication for mental illness, is actually prescribed by primary care, not by psychiatrists. About 80 percent of antidepressant and anti-anxiety prescriptions are written through primary care. Increasingly, that specialty mental health sector is for people with serious mental illness who have either very complicated forms of depression or schizophrenia or bipolar illness that require antipsychotics and other interventions. What that means is that a lot of people with depression or anxiety get medicine but they don’t get psychotherapy. And we know for many people, particularly with mild to moderate depression, psychotherapy is as effective or in some cases probably more effective if you look at long-term outcomes. That’s certainly true with some forms of anxiety as well. These are very treatable problems, but I don’t think that primary care doctors are set up to do more than provide the medication. The beauty of collaborative care is it brings in somebody else who can help connect the person to psychological support, psychological care as well. We’ve done that beautifully in the UK, but not yet in the U.S. with the single exception of the VA system, which has done this really well.
For CEOs looking toward the future — whether mental health becomes a social movement, strategic imperative, or both — what should they be thinking about now to drive impactful change?
Insel: All of us have a role. There are two kinds of families in America: families that are struggling because a loved one has mental illness and families who aren’t struggling … yet. All of us will. We’re kind of becoming involuntary experts as we learn about it through our personal experience. Health care CEOs can start to make a difference by understanding that we cannot fix this ourselves. It’s like climate change in that we didn’t cause it and it’s not within our domain to do everything. But we can do something. Part of that is building out capacity so that when there are no beds, people don’t have to go to jail, they can actually come into health care. That requires thinking beyond our narrow idea of what health care looks like to consider more broadly those three Ps. That’s the bottom line: the problems are medical, but the solutions are social, they’re environmental, they’re political.
