Healing our broken mental health system, written by the guy at the center of it all.
Healing: Our Path from Mental Illness to Mental Health
Thomas Insel 2022
We all know that America's healthcare system is an expensive mess. But did you know that our mental healthcare system is an even bigger mess? We know more about mental illness than ever, have more drugs at our disposal than ever, and yet for most people that suffer from mental illness the results continue to be disappointing as substance abuse and suicide keep rising. Why is our system so inadequate? Where are we making progress? And how can we fix it so it works better for everyone?
In this groundbreaking book, Thomas Insel gives a harsh diagnosis of how our mental health system works now and how it can be so much better. Healing tells the tale of how we can transition from a system that focuses on band aid solutions in crisis situations to one that identifies and supports vulnerable people before they ever reach the crisis point. Dr. Insel knows what he's talking about. He is an American neuroscientist, psychiatrist, entrepreneur, and author who led the National Institute of Mental Health from 2002 until November 2015. This is his first book.
Why, with all of the billions of dollars that we spend on mental health care are outcomes so disappointing? Why are so many of the seriously mentally ill being cared for in jails and shelters? The answers to these questions are enlightening and Dr. Insel's recommendations make a lot of sense. He covers the history of mental illness in America, pointing to 1963 as a turning point. President Kennedy signed a bill to set up community-based health plans and shut down the many large mental institutions that had been housing mentally ill patients. (90% of the beds for mental patients nationwide were eliminated by this move). LBJ added Medicaid and SSI in the late 1960's to give the mentally ill some basic income on which to survive.
But then Ronald Reagan in the 1980's cut back most of the federal money, leaving it to each state. That left behind a broken system and no place for the mentally ill to go unless they were in serious crisis. That's where we are today- reliant on crisis care for the psychotic and suicidal, but with little for the anxious and depressed who make up the bulk of the problem.
Today only about 40% of the people who need mental healthcare get it, and of that number only 40% get minimally acceptable care. For various reasons only one third of those who get the minimal care show actual positive progress, which works out to 5% of the people needing help actually succeeding. That comes from some $280 Billion in spending every year.
There are a variety of treatments for mental illness that have proven to work. The problem is that no one treatment works on everybody all the time, and sometimes treatments work wonders and other times they stop working completely. These are the ones that Insel focuses on:
- Drugs. One out of every six Americans is on some kind of drug to help with anxiety, depression, mood, psychosis, ADHD, and other maladies. Many of these drugs work as intended, and most have side effects that can be problematic. One big problem is that patients rarely take the drugs as prescribed, missing doses because of financial problems or other challenges. In the long run, drugs can relieve symptoms but don't cure the underlying causes of mental illness, so it gets complicated.
- Psychotherapy. There are many versions of therapy and many categories of therapists. Sometimes they work wonders, but the big challenges remain getting the patients to accept that they need therapy and finding the right therapist and type of therapy that families can afford. Therapists are unevenly distributed, with few in rural areas. They can also be poorly trained for many diagnoses and are unaccountable for results in most cases.
- Neurotherapeutics. This includes one old solution- electro-convulsive therapy (ECT), and one new one- repetitive transcranial magnetic stimulation (rTMS). ECT involves passing non-lethal electric currents through the body, while rTMS involves using magnets to stimulate specific areas of the brain. We still don't understand why these work, but they sometimes work wonders.
Ideally, according to Dr. Insel, any or all of these treatments would be ongoing and combined in one overall treatment plan that follows each person throughout their lives. But here's the problem in a nutshell- our system is set up so that each therapist and doctor is a separate entity, and they don't collaborate with each other. Most people get their drugs from a general practitioner who knows just the basics about mental health, and they rarely talk to therapists to coordinate care. The mental patient is supposed to keep track of everything, and they just aren't capable of monitoring their own care in many cases. Plus when people move often, their records get lost and ongoing supportive care becomes impossible. We fall back into crisis mode.
The things that make our healthcare system inefficient make mental healthcare doubly inefficient. The for-profit nature of the system leaves a lot of people unable to participate. The majority of therapists don't take Medicaid, 40% don't take Medicare, and many don't take any insurance at all. Insurance companies dictate care for those lucky to get any, and patients have to get in truly life-threatening situations before insurance foots the bill. And then once the symptoms lessen, there is no follow-up and behavior often deteriorates again. In a broken system like this, jails become the de-facto treatment centers of last choice, and they have no follow-up either. Then people end up homeless or dead.
Dr. Insel points to a new paradigm of mental health care that emphasizes the 3 P's- people, place, and purpose. People suffering from serious mental illness often find themselves isolated and alone, either because they were shunned by society or because their illness isolates them psychologically. Making sustained progress in mental health requires caring, loving, and stable people that can relate to patients. Place refers to supportive housing that is safe and nurturing. Jails, the streets, unsafe homes, and general chaos in living arrangements prevent progress in care. People need a safe, reliable place that they can go to for them to be able to calm their fears and illusions down. And finally there is purpose. We all need a reason to live in order to stave off the demons of substance abuse, depression, and suicide. Many of the most chronically mentally ill are unemployed, but most of them want to work. True mental health care has to end with helping to find these people a way to contribute, fit in, and find meaning.
There is a fourth P- prevention that Insel is very optimistic about in his Ted talks and in the book. The secret of preventing so many diseases like cancer, heart disease, and stroke is early detection and treatment. He believes that advances in brain scanning and knowledge will soon allow us to detect serious mental illnesses before any symptoms emerge. Early treatment saves lives and money by catching a disease before it has a chance to ruin years and lives. Already we know a lot about what people are most at risk for serious mental illness- foster children who are aging out of the system, LGTBT teens, and children who experience "adverse childhood experiences" like rape, murder, or violence in their families. Adults, especially older adults who experience losses- especially lost jobs or lost loved ones are also at higher risk.
Bottom line- we need a mental health system that
- Emphasizes early detection and prevention
- Offers affordable and and accessible treatments that are geared towards helping the specific needs of each person
- Offers holistic care for the 3 P's- person, place and purpose
- Monitors results and continually seeks to improve upon them. Every provider must become accountable and follow-up with patients, especially after crisis episodes
This book is excellent and the best one I've ever read on the mental health system. I recommend it to anybody who has experienced mental illness in themselves or a loved one, or who works in the field. It is full of frustrating stories, but also inspiring ones, and it's nice to hear that progress may be on its way.