US prisons contain people with 10 times more severe mental illness than state mental hospitals.Credits: Lucy Nicholson / Reuters / Alamy
Healing: Our Path from Mental Illness to Mental Health Thomas Insel Penguins (2022)
The kidnapper takes a psychiatrist and a cardiologist hostage. He promises to release the one who has done the most for mankind and shoot the other. Cardiologists explain that medicines and procedures in her field have saved millions of lives. Psychiatrists begin rebelliously: “The thing is … the brain is the most complex organ in the body.” “You can’t hear this again,” says the cardiologist. “Shoot me now.”
This is one of the jokes scattered in the early chapters of healing by Thomas Insel, a former director of the National Center of Neurology and Psychiatry (NIMH), USA. Treatments have been scientifically proven to address at least some of the symptoms. So why does Insel not improve the rates of suicide, premature death, homelessness and unemployment in people with serious mental illness?
In his easy-to-read and compelling book, Insel answers his own questions through personal stories and statistics. He sets up recipes for better care and access to that care. This requires politicians to invest more and be smarter in supporting mental health.
Insel knows what he is talking about. After working for NIMH from 2002 to 2015, he led the mental health team at Google’s life sciences spin-off company, Verily, in South San Francisco, California. In 2019, he was the Governor of California’s Mental Health Advisor, investigating many issues in state care.
There are 47,000 suicides each year in the United States. At least two-thirds are associated with people with serious mental illnesses such as depression and schizophrenia. Suicide mortality is three times higher than homicide mortality, and is steadily increasing, despite declining in other countries. On average, people with severe mental illness die about 20 years earlier than the average US population due to other causes, such as heart disease and cancer, because they are not treated. In terms of life expectancy, I live like in the early 1920s.
Insel’s joke was right for the cardiologist to claim success. Mortality from heart disease in the United States has been more than half since the 1950s, primarily thanks to drugs that lower cholesterol and act on high blood pressure. Treatments for serious mental illness are far less effective. Only one-third of those treated respond well and one-third do not respond at all. The problem — and don’t shoot me — the brain is really complicated. Neuroscientists have a rough understanding and struggle to find the exact target of treatment.
Access to care
Insel claims that more can be done by increasing access to appropriate care and improving the quality of that care until the treatment improves. Only about 40% of people with mental illness in the United States receive some form of treatment, of which about 40% receive evidence-based treatment. As a model, Insel proposes a treatment for pediatric acute lymphoblastic leukemia that showed 90% mortality in the 1970s and now shows 90% survival thanks to better management of the same drug. .. Similar improvements can result from incorporating drugs and psychotherapy for serious mental illness into an extensive care program.
One challenge is that the US system was developed primarily to address mental health crises and does not provide long-term management and recovery. The first antipsychotics were introduced in the 1950s and were able to control some serious symptoms and release people from often brutal psychiatric facilities. The Community Mental Health Act of 1963 established treatment at local health centers as an alternative to institutionalization. However, little money came out and tens of thousands of people ended up in a community that wasn’t ready to deal with their condition.
Medicaid — the US public health insurance system for people with limited incomes, introduced in 1965 — does not (and pays) for adults to stay in a mental health facility with 16 or more beds. not). Those who could rely on private facilities. Others have been imprisoned or out on the street. Prisons and prisons are effectively mental hospitals, Insel writes. According to a 2014 survey, US prisons had people with 10 times more severe mental illness than state mental hospitals (see go.nature.com/3kccfca).
Inadequate investment in mental health care is not unique to the United States, and many countries have freed people from institutions when drugs become available. But most rich democracy has a stronger culture of social welfare.
Insel advocates a wide range of care involving an integrated team of psychiatrists, psychologists, primary care nurses and social workers. Overcoming a mental health crisis does not always help with a long-term outlook. They need help to continue taking medicines, maintain general health, and get their personal lives back on track.
Insel describes a program that checks many of these boxes. Some are in other countries (eg UK) and others are around the United States. He praises NIMH’s Collaborative Specialty Medical Initiative for those who are experiencing the first episode of mental illness. After promising early results, it is being rolled out nationwide.
The quality of care also needs to be improved. Although most psychiatrists have a sound science education, less than 40% of US Master of Psychology and Social Work programs train students on science-based treatments. Only 18% of psychiatrists and 11% of psychologists regularly manage symptom assessment scales to monitor patient progression.
Few people argue that politics can and should improve the harsh conditions of people with mental illness. But funding better care should not interrupt the US government’s strong investment in basic neuroscience. This includes the BRAIN (Brain Research through Advancing Innovative Neurotechnologies) initiative worth an estimated US $ 6.6 billion from 2017 to 2027. This number is dwarfing similar programs in other countries.
Such generosity is needed. The patchy performance of current therapies can only be improved with a more complete understanding of the brain, but this takes time. Insel points out this point, but does not elaborate on it. After all, he has spent time on his basic research. This book reflects his nearly damascene perceptions of racism, inequality, poor housing and education, and the limits in the face of community collapse.
