It may come as a surprise to learn that serious mental illnesses, such as schizophrenia, bipolar illness, and severe depression, affect approximately one in 20 Americans. Some of us have encountered these conditions in the experience of members of the family. Others see it regularly displayed on the streets of the city. By now, as Thomas Insel notes in “Healing: Our Path from Mental Illness to Mental Health,” we know a lot about the brain and the ways it can malfunction. Yet outcomes for people being treated for serious mental illness are often poor, he says. Why?
Healing: Our journey from mental illness to mental health
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A psychiatrist and neuroscientist who led the National Institute of Mental Health from 2002 to 2015 and has since returned to the private sector, Dr. Insel is well placed to answer the question. In “Healing”, he describes the treatments that currently exist, outlines the barriers that many people face, and shows how healing programs could be designed to work better. The heart of his argument is quickly grasped: “We are not taking advantage of the science we have.
Dr. Insel begins his analysis with two contrasting scenarios. Young Roger was once a neighbor of his: During Roger’s senior year of high school, he began to hear “alien voices”. A doctor prescribed a crucial drug, but Roger stopped taking it. He became so agitated that his father had to call 911, and the police were dispatched. Hospital beds were scarce, and state law prohibited committing Roger to involuntary care. Psychotic and unable to take care of himself, Roger was left homeless.
Dr. Insel met Brandon at a mental health fundraiser several years ago and learned of his story. By his late teens, Brandon had become increasingly irrational. Unlike Roger, however, he was able to embark on an ongoing, coordinated long-term plan that addressed all areas of vulnerability. There was medication for his delusions and coaching for his social skills. He received employment assistance. Brandon, says Dr. Insel, shows what can happen. Roger’s much more common story reflects the “crisis of care”.
The statistics are depressing. Only about 16% of people with serious mental illness receive even “minimally acceptable” treatment. Many more end up in jail cells or squalid street encampments, or languish in back rooms. Psychiatrists are heavily concentrated in high-income urban areas, with half of all US counties having no psychiatrists. Paying for treatment can also be a challenge: almost 60% of psychiatrists do not accept Medicaid and 45% do not accept private insurance. There are only 12.6 public hospital beds for the mentally ill per 100,000, a quarter of what analysts say we need.
These serious shortcomings lead Dr. Insel to study programs which, in their creativity and effectiveness, are worth emulating. Roger’s father, it will be remembered, had been so afraid of his troubled son that, like other parents in such circumstances, he ended up turning to the police. In Maricopa County, Arizona, on the other hand, parents (or anyone concerned) can call a special toll-free number. A dispatcher deploys a van with a mobile crisis team, including a psychiatric nurse.
The University of Washington in Seattle has developed so-called collaborative care. A staff member is assigned to focus on “people who may not be asking for help or falling through the cracks,” as the program director puts it. “This person’s job is to integrate medication and psychotherapy with programs to meet social needs. In Britain, the Improving Access to Psychological Therapies program has trained over 7,000 therapists; they provide help with anxiety and depression to nearly 600,000 patients every year, as Dr. Insel reports.
Dr. Insel emphasizes that well-designed recovery programs should aim to “find connection, sanctuary, and meaning not defined or bounded by mental illness.” Ideal long-term care, after initial contact, would include the sustained attention of a team, including a social worker and an occupational therapist. One of the goals would be to help the patient navigate a return to school or work, thereby avoiding isolation and self-destructive rumination.
Because Dr. Insel is such a low-key writer, it’s easy to miss the boldness found in “Healing.” He admits to having long “misunderstood the problem” of mental illness treatment, as did much of the profession he helped lead for two decades. “As we studied risk factors for suicide, the death rate jumped 33%,” he writes. “As we identified the neuroanatomy of addiction, overdose deaths tripled. As we mapped the genes for schizophrenia, people with the disease were still chronically unemployed and dying 20 years earlier.
The reality of this failure dawned on him a few years ago during a public lecture in Portland, Oregon. He was looking through a PowerPoint presentation highlighting the accomplishments of his scientists at the National Institute of Mental Health: high-resolution scans showing brain changes in people with depression and abnormal ramifications in the neural cells of children with schizophrenia. .
The first question came from an exasperated father in the audience. He said his schizophrenic son had been in and out of hospital, had attempted suicide several times and was now homeless. What, the man wanted to know, were all these great lab discoveries doing for his child? “My mouth suddenly felt dry,” writes Dr. Insel. “But then I knew he was right.” Nothing in the lab per se addressed “urgency or magnitude of suffering”.
Dr. Insel took advantage of the revelation, traveling extensively to identify the care crisis and seek solutions. “Healing” is the product of that odyssey and a compelling summary of everything he learned along the way.
Dr. Satel is a Senior Fellow at the American Enterprise Institute and a Visiting Professor at Columbia University’s Vagelos College of Physicians and Surgeons.
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