Book Review: An Urgent Plea for Mental Health Care Reform

Yves here. I don’t know whether to be cheered or depressed to learn that there are sound and often successful approaches for treating severe mental health problems. But for the most part, we don’t do them due to how we do medicine.

By Joshua C. Kendall, a Boston-based journalist and author. His reporting on psychiatry, neuroscience, and health policy has appeared in numerous publications, including BusinessWeek, The Boston Globe, The New York Times, The Los Angeles Times, The Daily Beast, Scientific American, and Wired. Originally published at Undark

In the mid 1980s, as he was launching his academic career, psychiatrist Thomas Insel decided to research the neural pathways for social attachment. His work ended up documenting the important roles that the hormones oxytocin and vasopressin play in both parental care and monogamy. But despite his pioneering findings, he was fired in the early 1990s from his post at the National Institute of Mental Health. His alleged offense, Insel says, was focusing on the “soft science” of attachment rather than the “hard science” of motor control or visual processing.

By the time Insel was appointed director of the NIMH in 2002, his research interests no longer fell outside the scientific mainstream. By then, he had morphed into a fierce advocate of the dominant paradigm that has been driving psychiatric research for the past generation. During his 13-year stint as “America’s psychiatrist,” he devoted the bulk of his $20 billion budget to neuroscience and genomics. While he has no regrets about any of his funding decisions, he seems disappointed that he never achieved his overriding goal, which was to develop a biomarker for depression or a molecular target for schizophrenia.

BOOK REVIEW“Healing: Our Path from Mental Illness to Mental Health,” by Thomas Insel (Penguin Press, 336 pages).

As Insel acknowledges in his new book on the state of our nation’s psychiatric care, “Healing: Our Path From Mental Illness to Mental Health,” this failure to make a major difference in the lives of people suffering from serious mental illness — say, chronic major depression or schizophrenia — haunts him. “Our science was looking for causes and mechanisms,” he writes, “while the effects of these disorders were playing out in increasing death and disability, increasing incarceration and homelessness, and increasing frustration and despair for both patients and families.” He argues that while research should continue to play the long game, mental health policy urgently needs major reforms now.

Putting on the hat of a journalist, Insel tries both to diagnose the reasons why so many psychiatric patients fare so poorly and to figure out what exactly can be done to improve their lot. To his credit, he does a thorough job of reporting and interviews a wide range of sources, including numerous patients, affected family members, mental health advocates, clinicians, and policy makers.

As Insel notes, according to a 2006 report from the Substance Abuse and Mental Health Services Administration, Americans with serious mental illness typically die 15 to 30 years earlier than the rest of the population. He places the blame largely on political and economic factors. He notes how former President Ronald Reagan dramatically cut federal spending on community mental health centers and other psychiatric services for low-income patients, who have also been squeezed by the gradual erosion of the social safety net in the past few decades.

In our profit-driven society, Insel laments, the mental health care system isn’t just broken but has completely vanished: “At best, we have a mental sick-care system, designed to respond to a crisis but not developed with a vision of mental health that is focused on prevention and recovery.” This sick-care system, he stresses, was built by insurance companies and drug companies. And tragically, Americans without private insurance often have difficulty accessing needed services — say, a hospital bed — even in times of crisis. In most developed countries there is an average of 71 public psychiatric beds per 100,000 people; in America, the corresponding figure in 2014 was just 12.6, according to the National Association of State Mental Health Program Directors.

Moreover, even insured patients who receive inpatient treatment tend to face the formidable challenge of what he calls a “service cliff” upon discharge. Given that the primary objective of pricey short-term hospital stays is to stabilize patients on a cocktail of psychotropic medications, little thought is given to setting up a viable long-term care plan. “Hospitalization in such a scenario,” writes Insel, “is a railway stop on a journey with no evident connection to the stops before or after.” As a result, the so-called revolving door syndrome — in which desperate patients end up returning to the hospital on numerous occasions — is not uncommon. 

But despite these formidable socio-economic obstacles, Insel insists that effective mental health care is available. He maintains that today’s standard treatments — namely medications including antipsychotics and antidepressants, along with psychotherapy — can work relatively well when they are properly administered. The problem is that patients are rarely matched with the appropriate specialists. As he notes, nearly 80 percent of antidepressant and anti-anxiety medications are prescribed by primary-care physicians, rather than by psychiatrists.

Insel also argues that only a small percentage of the nation’s 700,000 mental health providers offer state-of-the-art psychotherapy. Rather than relying on scientifically proven treatments such as cognitive behavioral therapy, clinicians often turn to the faddish approaches championed by a few charismatic practitioners. In his view, psychotherapy should be carefully monitored by a regulatory body so that more patients would receive evidence-based care rather than “eminence-based care” (to use his neologism, which attempts to account for why patients are often ill-served by their therapists).

In the most moving section of the book, Insel emphasizes that addressing the scourge of serious mental illness requires more than just doling out the right medical solutions. During a visit to Skid Row in Los Angeles, he interviewed a clinician who told him that recovery revolved around “the three Ps, man.” As Insel admits, he initially thought that this cryptic phrase was a veiled reference to three popular drugs: Prozac, Paxil, and Prolixin. But when the clinician explained that he was referring to “people, place, and purpose,” Insel had an aha moment.

As he now realizes, people suffering from serious mental illness have the same aspirations as everyone else. To lead a fulfilling life, they also need to forge deep human connections, find a safe place to live, and find meaning in this far from perfect world. And Insel highlights how a series of innovative programs are already helping countless patients do just that. For example, over the last seven decades, mental health advocates have created 330 clubhouses in 33 countries around the world. These “intentional communities,” he writes, provide recovering patients with social support, a place to meet and eat meals together, and to access job placement services.

Insel’s foray into journalism has convinced him that science and technology alone — including new drugs or smartphone apps — will never be able to cure any form of mental illness. That’s because in contrast to cancer treatment, mental health treatment inevitably requires more than just rooting out the disease in the body. But his newfound sensitivity to the daily struggles of psychiatric patients raises a host of compelling questions about the future of the NIMH, which he glosses over.

The NIMH was established in 1949 to fund not just research, but also efforts to treat and prevent mental illness. However, since the late 1980s, all its leaders, including Insel, have reinterpreted its mission, choosing instead to focus almost exclusively on basic science. So if, as Insel concedes in his book, decades of brain research have led to few tangible results, should the federal government continue to spend billions of dollars on purely theoretical studies? Or, should, as critics argue, many of these scarce dollars instead be allocated to social programs that can either help prevent or treat mental illness? For example, as Allen Frances, the former chair of the psychiatry department at Duke University, recently put it at Aeon: “The NIMH is entitled to keep an eye on the future, but not at the expense of the desperate needs of the present. Brain research should remain an important part of a balanced NIMH agenda, not its sole preoccupation.”

Insel’s reflective and heartfelt book is an important contribution to the ongoing debate about how to address the current crisis that prevents so many Americans saddled with a serious mental illness from rebuilding their lives. “Recovery,” he stresses, “is both a goal for an individual and a necessity for healing the soul of our nation. Our house is on fire, but we can put the fire out.”

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  1. upstater

    Looks like an interesting read…

    While COVID has laid bare problems and failures of public health and pandemic management, the failures of the mental health system have always been exposed for all to see. Any walk through the edges of a downtown area, shelters or homeless encampment one will encounter the consequences of mental health failures.

    The root of the problem is stigma. People with mental illness and easy to stigmatize and be fearful of due to behaviors and appearance. Add to it the gun crimes comitted by untreated schizophrenics like Aurora or Tucson and it is easy to be fearful and generalize. Consequently they become disposable Untermenschen; their suffering on the fringes of society is exactly why life expectancy is so much lower. Mental health wards in hospitals are often dreadful places and understaffed.

    There is a singular focus on sedating neuroleptics for psychotic illnesses. While successful treatments with antipsychotics can provides a modicum of normality, they come with a huge list of side effects such as weight gain, neurological damage (e.g. tardive dyskenesia), diabetes and so much more. Side effects are a major barrier for compliance. There are more than a dozen commonly used antipsychotics and finding the right one is a lengthy process taking weeks or months. Psychiatric providers often simply do not have the time or resources for this standard of care. Therapy is necessary to help a person understand their illness, but is even more constrained.

    Opportunities for housing, socialization and working are threadbare. Group homes or section 8 apartments are often not nice places to live. While having clubhouses is helpful, this doesn’t mainstream the mentally ill which can build confidence and acceptance. Work opportunities are much the same. Sheltered or menial work is helpful, but many people have high skills levels that are not utilized because employers don’t want the hassle of accommodation, in spite of what the ADA says.

    Lastly, like eldercare, mental illness is often managed by families. The financial and time burdens are significant. But without familial support many mentally ill people end up on the streets or worse. A symptom of a failing state…

  2. Joe Well

    “People, place, purpose.” I’m going to remember that as a mantra.

    But with rents what they are, and jobs and jawbs what they are, very difficult to achieve secure job and housing in most places, impossible in many. It strikes me that the ideal mental health outcome assumes a kind of 1970s USA with abundant apartments and 40-hour-a-week jobs.

    1. Carla

      @Joe Well — I know. It’s to the point where I’m starting to think anyone who seems mentally healthy is actually insane.

      Agree that “People, Place, Purpose” are the essential elements of a life worth living. In “Evicted,” Matthew Desmond ably explained how it is practically impossible to remain sane if one is homeless.

    2. Jeremy Grimm

      An observation pregnant with meaning and implications:
      “…people suffering from serious mental illness have the same aspirations as everyone else. To lead a fulfilling life, they also need to forge deep human connections, find a safe place to live, and find meaning in this far from perfect world.”
      What people, whether mentally ill or otherwise, need are “people, place, purpose.” But as you indicate those basic needs are increasingly unavailable in our lives. How much does their lack contribute to the incidence of mental illness and what does the present course of Society suggest for the future? — more madness I think. Our Elite are fashioning a favorable environment for the mindless mobs they fear.

      One thing not mentioned in the post, that I have seen in the jail, mental hospital, and ‘half-way’ house where my son has been incarcerated over the years — is the incredible boredom and hopelessness nurtured in all these situations — even worse than at typical jobs and in schools. [My son seems to be getting worse after mental health treatment by the State.]

      1. Joe Well

        >>I have seen in the jail, mental hospital, and ‘half-way’ house where my son has been incarcerated over the years — is the incredible boredom and hopelessness nurtured in all these situations

        I hope it doesn’t sound trite, but he is lucky to have a parent who care for him.

        I once visited someone in prison in Massachusetts, one of the lower-security level prisons, and the boredom was killing him. There was a six month wait to get a job in prison, barely paid at all, just sweeping the floors, he only wanted it so he could get out of his cell, or to get GED courses or do anything that would get him out of his cell for more than meals and exercise. Meanwhile, the families were getting fleeced on expensive collect phone calls and overpriced items in the prison store.

  3. Stick'em

    Not much is going to change with pharma companies pushing antidepressants that don’t work. These drugs don’t make people happy. In general, antidepressants make people feel different than they did before. Benadryl can do that much… doesn’t mean it cured anyone of depression.

    “Antidepressants are supposed to work by fixing a chemical imbalance, specifically, a lack of serotonin or norepinephrine in the brain. However, analyses of the published and the unpublished clinical trial data are consistent in showing most (if not all) of the benefits of antidepressants in the treatment of depression and anxiety are due to the placebo response, and the difference in improvement between drug and placebo is not clinically meaningful.”

    Furthermore, the “chemical imbalance” model is a marketing scheme. Just like the Secret antiperspirant “pH balanced for a woman” line.There’s a normal human reference range for pH. There’s no meaningful difference between male and female pH in human beings. If my pH is 7.4 and yours is 8.4 you’re dead – duh! Marketing has no meaning in biochemistry.

    Conversely, there is no definition of what a “balanced” brain looks like, no biological reference range for normal brain chemicals the way normal pH = 7.4. Therefore, there can be no definition of what an “imbalanced brain” looks like either. Somebody just made it up as a sales pitch, it was promoted to the heads of psychiatry at the university hospitals, and thus the “chemical imbalance” hypothesis basically became its own religion in psychiatric practice.

    This issue remains the ginormous Dumbo in the room frantically flapping its epic ears. Our mental health problem isn’t going to get fixed as long as we adhere to the mistaken belief depression is going to be resolved chemical imbalance marketing jingle way, no matter how much money is thrown at the problem. Which may be the real goal…

  4. Sarah Henry

    Re: those smartphone apps…how much (and what kind) of personal data are these things hoovering up on an already vulnerable subset of the population? What sort of privacy policies do they have in place, and do their developers in fact abide by them? The linked article doesn’t even address the risks to mentally ill patients from poor data-handling practices, which is disappointing.

  5. hemeantwell

    Schizophrenia is something of a catch-all diagnostic category and covers a broad range of symptoms and degrees of debilitation. It has been established that at least some patients respond quite well to psychotherapy. In their 1981 book, Psychotherapy of Schizophrenia: the Treatment of Choice, Bert Karon and Gary Vandenbos reported research conducted by the Michigan State Psychotherapy Project that summarized their own work and that of other psychoanalytically-oriented researchers. In my view, their case histories prove that at least some patients, including a number who had suffered from severe symptoms on the order of years-long catatonic states, would greatly benefit from a “talking cure” carried out by an experienced practitioner. I strongly recommend the book for anyone who would like to gain a more fully-rounded understanding of both the illness and the problems facing those who advocate treatment that downplays the use of meds.

    I’ll offer a vignette. I once was asked to meet with a young man who had achieved a precarious stability but who appeared to be on the verge of a serious decompensation. He was gradually slipping back into a delusional world in which he would obsessively develop plans to build a giant space station around a star to absorb all its heat and light. Previously he had undergone a long hospitalization during which the delusion was treated as one of a number of “disordered thoughts,” as he learned to put it, that he had been encouraged to ignore. After talking with him for a few minutes it became clear to me that the recurrence of the delusion was somehow related to worries about his relationship with a girlfriend. Instead of trying to keep the two areas of his experience separate I played a hunch and told him I thought that his worries about losing his girlfriend had led him to try to come up with a way of keeping himself warmed by a source that would last forever. This clicked strongly for him and helped to diminish the obsessive captivation of the star station. Fortunately the relationship with the girlfriend was pretty durable and he was able to engage her reparatively, he worked out something with her instead. (Weirdly, the space station around a star delusion has now been turned into a video game. )

    I hope this doesn’t come across as self-congratulatory. The point is that I had training that gave me a basic understanding of the sort of symbolic transformations that can render fairly straightforward emotions bizarre, frightening and radically isolating. I didn’t meet with him much longer, but my impression was that the basis for the delusion lay in the sort of horrible family situations that Karon and Vandenbos document. While there is definitely some merit to the critique of rigid mother- or family-blaming interpretations of schizophrenia, the implications of that critique have been overgeneralized. Sometimes people have been so terrified and overwhelmed as children that they create preservative retreats they cannot escape from on their own. With well-attuned, tactful help they can, and the person providing it has to be adequately prepared. This doesn’t necessarily mean that psychotherapy-based treatment would cost more. As Karon and Vandenbos demonstrate, outcome studies show a substantial long-term benefit that compensates for the initial cost of therapy.

    1. Jeremy Grimm

      I believe your patient was fantasizing about a Dyson Sphere. I have noticed the idea showing up fairly often in the science fiction literature I have read.

      I agree with the value of psychotherapy as a better treatment approach than a reliance on drugs — which too often seem to have been prescribed to “control” a patient with little concern for treatment. I believe that one of the keys to the effectiveness of psychotherapy is listening. A psychotherapist might be a better listener, but anyone might learn to listen to others and learn empathy with them. In this, I believe there is value to the listener being from ‘outside’ the realm of family. Some things are difficult or impossible to say to family or hear from family.

      Your patient’s Dyson Sphere obsession suggested a skew thought to the intent of you comment. I have observed what to my lay eyes appeared to be obsession driving the creation of many works of art and science. From this I recalled the world without emotion in “Fahrenheit 451.” My son’s madness lead to my suffering physical injury and pain, so I am not fan of madness — but not all madness is so destructive or self-destructive. Perhaps rather than control madness, it might be better to also channel all but the most profound madness in productive directions.

  6. Susan the other

    Do other social species have these problems? Or just us humans? (I’m familiar with stories about wolves being kicked out of the pack; “lone wolves.”) You’d think that if scientists were working on basic brain/emotional science that some research somewhere would be doing comparisons of groups of people with groups of chimps or some other social animal. It’s not out of the question that there really is a “molecule” involved. Even one generated by negative reinforcement. But that just begs the question. The reality we face of depression and despair in our failing society is less science and more social. It is almost (as the author implies) sadistic – to avoid blaming society by insisting it is something that only psychiatry can solve with proper drugs and therapy. Because it allows government to do nothing. We’ve consistently had over 500-thousand homeless people – at any given time – over the decades. I’m assuming that roughly reflects the tents on the street and people sleeping in doorway and parks. And moving as many as possible into apartments is happening in places like California. But our entire society is failing; it cannot control its own disintegration with little adjustments here and there. It is our society that needs help. And where are all our high-flying capitalists when they have eaten up all the profits? This is an obvious opportunity; a problem waiting to be solved. Good green jobs come to mind. The Big Illusion that needs to be resolved before anything meaningful can go forward is “Who pays?” The answer is everybody and nobody. Because we all benefit. What we desperately need is new legislation that makes it a crime for any representative to fail to address the needs of society in a timely manner.

    1. JEHR

      Susan, you have some very thoughtful ideas. So much of what you are saying is true of a lot of countries in the world, even the ones that look like they have it “put together.” Wherever financial capitalism resides, there are problems a-plenty.

  7. John Hacker

    The idea of smartphone apps is interesting. i agree it’s not the answer. After John Oliver’s commentary on how to gather data from data brokers the people freely give away online.
    John dropped a hook into the water and the respondents clicked the bait. i think the NIMH and the American Psychiatric Association could have plenty of data from brokers. Learning what it tells us is the question.

  8. Dave in Austin

    Sad situation:

    “In most developed countries there is an average of 71 public psychiatric beds per 100,000 people; in America, the corresponding figure in 2014 was just 12.6, according to the National Association of State Mental Health Program Directors.”

    We closed the mental hospitals in the 1970s to “free the patients”. I worked on one of those hospitals for a while. Terribly depressing. Americans are such optomists. We set the patients free then we discovered “not much works”.

    And that includes most psychiatric services; the few double blind studies done show almost no results. Drugs help the behavior but at significant cost to the person and are not a cure but we still use them. Like plasma for the dying soldier; “Not much but its all we’ve got that seems to help.”

    I have a close friend who has helped house a large number of street people; the best candidates are over 40, partied-out and just looking for a little place to live. The best social workers he’s found are religious ex-ancholics.

    The parents… what a trial. As they get older one question preys on them. “After I go… what?”

    And poor Dr. Insel. He spends his career looking for the chemical or genetic magic bullet and in the end discovers there are none.

  9. antidlc

    Is it just me or is there a problem with the text? I see a big black stripe down the left hand side of the text.

    1. Carla

      I don’t have the stripe, but I sent it to my sister and she got the stripe. Weird. She said it made the article VERY difficult to read. I sent her the link to the original at Undark.

  10. roxan

    I ran a large, inner-city psych ER in Philadelphia. Families really suffer. Patients often won’t be admitted unless declared ‘a danger to self or others’. It’s not enough to destroy property, scream all night or engage any number of behaviors you would want to stop. Even when admitted–which might take two days in the ER, calling around the City to get approval–they might only get 23 hours, so the process would start over. Beds are, indeed, few and far between. Most of our patients were on Medicaid, if they even had that, and a sprinkling of Medicare. I had one bed reserved for ‘private payee’, so rarely filled that staff would stop by to stare in wonder. I hope Obamacare helped but I retired before then.That hospital went bankrupt, destroyed by the Allegheny fiasco. Each floor had around 80 beds, and there were a few floors, so a lot of beds, gone. Temple hospital shut one psych ward, so were down to maybe two dozen beds. Hahnemann had nothing. And so on….

  11. David in Santa Cruz

    I read another review of Insel’s book in the Failing NYTimes that made it sound as if had not the slightest criticism or regret about the direction of the NIMH. Honestly, the FNYT article seemed nonsensical.

    I have had a lot of professional (as a prosecutor in a Mental Health “Problem-Solving” Court) and personal (as the father of a mildly autistic adult child whose “magic-pill”-seeking resulted in an involuntary hospitalization) experience of our failed, essentially nonexistent, mental health “system.”

    People, Place and Purpose are far more significant to recovery than pharmacology or neuroscience. The twin turds Ronald Reagan and Bill Clinton destroyed the mental health system in favor of looking for a “magic pill” cure-all that negates the expense of providing the Three P’s to people in crisis. I was going to ignore Dr. Insel’s book. After seeing this I might actually go out and buy it!

  12. expat

    There is no affordable, accessible mental health system in USA comparable to that of more developed countries. My daughter who grew up in the USA had a history of depression for which she received counseling by a psychologist but medication was not deemed needed at the time. She went to university in Poland but at age 21 had a major psychotic event. She was involuntarily committed to a mental institution there for 1 month. She received excellent care and we both will be forever grateful to the doctors and nurses there. Upon her return to the USA the psychologist who previously treated her told us that she was extremely lucky she was in Poland when the episode occurred as she would have never gotten that kind of care in the US unless we were very wealthy. From prior experience with the US mental care “system” I know this to be true.She remains on medication and is doing remarkably well. Will be attending graduate school in EU this fall. The cost for her care in Poland? Zero

  13. Deb Schultz

    I read the essay on the continuing popularity of “What Color is Your Parachute” before reading this. I would say that the 3 Ps is not going to make a dent in the deep perversion of personhood that has become the cornerstone of “democratic capitalism”.

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