Former US mental health czar calls for comprehensive care reform

Incarcerated people walk around an exercise yard outside the California Men's Institute State Penitentiary.

There are ten times as many severe mental illness patients in US prisons as state psychiatric hospitals.Credit: Lucy Nicholson/Reuters/Almy

Healing: Our Path from Mental Illness to Mental Health Thomas Insel Penguin (2022)

A kidnapper holds a psychiatrist and a cardiologist hostage. He vows to release the person who has done the most for humanity – and to shoot the other. The cardiologist explains that medications and procedures in her field have saved millions of lives. The psychiatrist begins by ruminating: “The thing is … the brain is the most complex organ in the body.” “I can never listen to this again,” says the cardiologist. “Shoot me now.”

This is one of the jokes that Thomas Insel, the former head of the US National Institute of Mental Health (NIMH), spreads through the early chapters of Healing, his investigative analysis of what went wrong in the treatment of mentally ill people in the United States. It has been scientifically proven that treatments relieve symptoms in at least some. Insel asks, then, why rates of suicide, early death, homelessness, and unemployment have not improved among those with serious mental illness?

In his readable and compelling book, Insel answers his question with anecdotes and personal statistics. Puts a prescription for better care and getting that care. It is a call for politicians to invest more in mental health support, and to do so more wisely.

Insel knows what he’s talking about. After his stint at NIMH from 2002 to 2015, he led the mental health team at life sciences spin-off Google Verily in South San Francisco, California. In 2019, he was a mental health advisor to the governor of California, exploring the many problems in the state’s care.

There are 47,000 suicides in the United States each year. At least two-thirds of the number includes people with a serious mental illness such as depression or schizophrenia. The death rate from suicide is three times that of homicide, and it’s steadily rising—even as it is declining in other countries. On average, people with severe mental illness from other causes, such as heart disease or cancer, die about 20 years earlier than the general US population, because they do not receive medical treatment. In terms of life expectancy, they live as if they were in their early twenties.

The cardiologist in Insel’s joke was right to claim success. Death rates from heart disease in the United States have more than halved since the 1950s, thanks in large part to drugs that lower cholesterol and work against high blood pressure. Treatments for serious mental illness are much less effective. Only a third of people treated respond adequately, and a third do not respond at all. The thing is – and don’t shoot me – the brain is really complex. Neuroscientists, with their simple understanding, struggle to find specific targets for treatment.

get care

Insel believes that until treatments improve, we can do more by increasing access to appropriate care, and enhancing the quality of that care. Only about 40% of people with mental illness in the United States receive any form of care, and of those, only 40% or so receive evidence-based treatment. Insell is proposed as a treatment model for childhood acute lymphoblastic leukemia, which had a mortality rate of 90% in the 1970s and a survival rate of 90%, thanks to better management of the same drugs. Similar improvements could come from including medications and psychological treatments for serious mental illness in a broad program of care.

One challenge is that the American system was primarily developed to deal with mental health crises, not to provide long-term management and recovery. The first antipsychotic drugs were introduced in the 1950s, allowing some severe symptoms to be controlled, and people released from often brutal psychiatric institutions. The Community Mental Health Act of 1963 established treatment at local health centers as an alternative to institutions. But too little funding emerged, and tens of thousands of people ended up in communities ill-equipped to deal with their conditions.

Medicaid – the US public health insurance system for people with limited incomes, introduced in 1965 – will not (and will not) pay adults for stays in mental health facilities with more than 16 beds. Those who can turn to private facilities; Others ended up in prison or on the streets. Insel wrote that prisons became de facto mental hospitals. A 2014 survey found that there are ten times more people with severe mental illness in US prisons than there are people with severe mental illness in state psychiatric hospitals (see go.nature.com/3kccfca).

Poor investment in mental health care is not limited to the United States alone, many countries have fired people from institutions as soon as drugs become available. But most wealthy democracies have stronger cultures of welfare.

Insel advocates for broad care that includes integrated teams of psychiatrists, psychologists, primary care nurses, and social workers. Just getting someone out of a mental health crisis doesn’t necessarily help their long-term prospects. They need support to stay on their medication, take care of their general health and get their personal life back on track.

Insel describes programs that check many of these boxes – some in other countries (the United Kingdom, for example) and some throughout the United States. He admires the National Institute of Mental Health’s coordinated specialized care initiative for people with a first episode of psychosis, where professionals collaborate to personalize care, provide psychotherapy, administer medications, educate and support family, and support work or education. It is being rolled out across the country after promising early results.

The quality of care must also improve. Most psychiatrists have a sound scientific education, but less than 40% of psychology and master’s programs in social work in the United States train students in science-based therapies. Only 18% of psychiatrists and 11% of psychologists routinely administer symptom rating scales to monitor patients’ progress.

Few would agree that politics can and should change the grim situation for people with mental illness. However, funding for Better Care should not interrupt the US government’s strong investment in basic neuroscience. This includes the BRAIN (Brain Research Through the Development of Innovative Neurotechnologies) initiative, which is estimated to be worth $6.6 billion from 2017 to 2027. This number dwarfs similar programs in other countries.

This generosity is required. The incomplete performance of current treatments can only be improved with a complete understanding of the brain, which will take time. Insel makes this point but does not elaborate. He has spent his time in basic research, after all, and this book reflects his semi-damask realization of its limitations in the face of racism, inequality, poor housing and education, and the breakdown of society.

conflict of interest

The author declares no conflict of interest.