In Dr. Thomas Insel’s new book about the mental health crisis in the U.S., he makes the stakes plain.
“Recovery is both a goal for an individual and a necessity for healing the soul of our nation,” he writes.
Insel, the former longtime head of the National Institute of Mental Health and one of the country’s leading neuroscientists and psychiatrists, argues that we’re witnessing a “crisis of care”: Most people with mental illnesses aren’t receiving treatment. Mental health care isn’t delivered effectively. And instead of focusing on prevention or recovery, the system is geared toward caring for people once they’re already in crisis.
The result, he writes, is that those with mental illnesses continue to live as “a people apart.”
As King County considers a property tax levy to build a network of mental health crisis centers — and state officials weigh plans to inject millions of dollars to expand behavioral health care — Insel spoke with The Seattle Times about his book “Healing: Our Path from Mental Illness to Mental Health,” and the role of communities, governments and health care systems in finding solutions. Insel is the co-founder and chair of the board of mental health startup Vanna Health.
This conversation has been lightly edited for length and clarity.
Over the past 60 years, we’ve witnessed what you call “undeniable” progress in our understanding of mental illness and the development of treatments. Why aren’t outcomes improving?
They’ve actually gotten worse. So, what’s going on?
The people who could and should be in care don’t get it until they’re very ill and they’re in an emergency room. Whenever you have a crisis, it’s because you’ve failed in some way upstream.
The other part is making sure they get high-quality care. That actually does make a difference. I maintain that we have good stuff to offer. People just don’t get it.
In your book, you talk about how the mental health crisis is also a crisis of community, economics and politics — not just a result of problems in the medical care system. What do you mean by that?
The reason why we have a sense that there’s a crisis isn’t because there’s a huge amount of increase in the prevalence [of serious mental illness]. It’s because there’s been a huge decrease in care. [Another] big problem here is not just access, it’s getting people engaged in care.
The big needs are around building capacity, figuring out how to solve the engagement problem and improving the quality of care.
We need to do a better job on accountability. Actually measuring outcomes and making sure that providers are held accountable for those kinds of outcomes. Not only providers, but leaders, governments [should be] held to outcomes: reducing incarceration, reducing homelessness, reducing suicide. There are really some remarkably profound needs that we just don’t track the way we track many other medical outcomes.
We have an equity problem here as well. It is even more difficult for marginalized populations of any sort to get care. Not just racial or ethnic or economic disparities. I’m really thinking specifically about the needs of people who have serious mental illness. Here we’ve got a group that’s worse off than any other minority group, in terms of employment and life expectancy and even incarceration rates.
What role should communities play in people’s recovery from mental illness or substance use disorders?
I had this idea that if we’re going to try to reduce suicide by 30% or 50%, and reduce incarceration and homelessness and all these issues around morbidity and mortality, we had to solve for all the deficits in health care. I began to realize that was kind of a pipe dream, that it’s a mistake to conflate “health” and “health care.”
The public health wizards in the country will tell you that health outcomes are only about 10% related to health care. It’s not like how many pills you’re on, or how many clinic visits you have. It’s where you live, who you live with, what you live for, how you live. And we don’t consider that health.
We have to redefine what we mean by health care. It’s providing what I call the “three P’s”: people, place and purpose. Social support, safe havens like clubhouses, and good housing. And then giving people something to live for, something to recover for, whether that’s work or school or a chance to help others who are going through the same thing through becoming peers. There’s just so much we can do here.
What societal factors contribute to mental illness?
The kinds of social determinants we worry about in the mental health space tend to be adverse childhood experiences, effects of foster care, what happens to youth who are involved with the criminal justice system. The role of everything from bullying to what poverty does to a young person growing up.
Unlike the rest of medicine, we’re often dealing with people in the first three decades or two decades of life, not in the latter half of life like you would for cancer or heart disease. Depression and anxiety and even eating disorders, all of that is significantly up [among youth]. It’s all the more important that we get it right and do it well. Not just being reactive, but getting proactive.
California has tried to take this on with a massive investment which will make the school system that center of gravity for behavioral health for kids. There’s a lot of opportunity here, but I don’t think it’s been fully realized in most of the country.
What has the pandemic taught us about community willingness to rally around public health crises?
Unfortunately, the vaccines became part of the culture war.
You’ll find that mental health has bipartisan support. Everyone is getting a greater sense, through the pandemic, that this is really an issue that does need attention, especially for young people.
How well can we come together to solve that? To what extent is America in a place where it wants to join forces? I don’t know. It’s difficult to see that sense of mission or commitment. We’ve gotten really sidetracked by so many issues, so much misinformation. We’re in a difficult place.
If we could make a commitment to the people who had the greatest needs, which are those people with serious mental illness, it could be healing for all of us. It’s not just a matter of healing them. It’s a matter of healing us.