Former US mental health czar calls for care overhaul

Prisoners walk through an exercise yard outside the California Institution for Men State Prison.

US prisons hold ten times as many people with serious mental illness as state mental hospitals.Credit: Lucy Nicholson/Reuters/Alamy

Healing: Our journey from mental illness to mental health Thomas Insell Penguin (2022)

A kidnapper holds a psychiatrist and a cardiologist hostage. He pledges to free the one who has done the most for humanity and shoot the other. The cardiologist explains that drugs and procedures in her field have saved millions of lives. The psychiatrist begins by ruminating: “The thing is… the brain is the most complicated organ in the body. “I can’t listen to this anymore,” said the cardiologist. “Kill me now.”

It’s one of the jokes Thomas Insel, former head of the US National Institute of Mental Health (NIMH), sprinkles throughout the early chapters of Healing, his in-depth analysis of what went so wrong with the treatment of people with mental illness in the United States. The therapies have been scientifically proven to address symptoms for at least some. So why, asks Insel, have rates of suicide, premature death, homelessness and unemployment among people with severe mental illness not improved?

In her readable and persuasive book, Insel answers her own question through personal stories and statistics. It offers a recipe for better care and better access to that care. It’s a call for politicians to invest a lot more in mental health support, and to do it a lot smarter.

Insel knows what he is talking about. After his stint at NIMH from 2002 to 2015, he led the mental health team at Google’s life science spinoff Verily in south San Francisco, California. In 2019, he served as mental health adviser to the Governor of California, exploring the state’s many care issues.

There are 47,000 suicides in the United States each year. At least two-thirds are people with serious mental illness such as depression or schizophrenia. The suicide death rate is three times higher than the homicide death rate and is steadily increasing, although it is falling in other countries. On average, people with serious mental illnesses die of other causes, such as heart disease or cancer, about 20 years earlier than the general US population because they do not receive medical treatment. In terms of life expectancy, they live like the early 1920s.

Insel’s joke cardiologist was right to claim success. In the United States, the death rate from heart disease has more than halved since the 1950s, largely due to drugs that lower cholesterol and work against high blood pressure. Therapies for serious mental illnesses are much less effective. Only a third of the people treated respond sufficiently and a third do not respond at all. The thing is – and don’t shoot me – the brain is really complicated. Neuroscientists, with their sketchy understanding, struggle to find specific targets for treatment.

Health care access

Until therapies improve, argues Insel, there is much more we can do by improving access to appropriate care and improving the quality of that care. In the United States, only about 40% of people with mental illness receive some form of care, and of these, only about 40% receive evidence-based treatment. Insel offers as a model the treatment of childhood acute lymphoblastic leukemia, which had a 90% mortality rate in the 1970s and now has a 90% survival rate, thanks to better management of the same drugs. Similar improvements could come from integrating medications and psychotherapies for serious mental illnesses into a broad program of care.

One of the challenges is that the US system has developed primarily to deal with mental health crises, not to provide longer-term management and recovery. The first antipsychotic drugs were introduced in the 1950s, helping to control some severe symptoms and freeing people from often brutal psychiatric institutions. The Community Mental Health Act of 1963 established treatment in local health centers as an alternative to institutionalization. But little funding emerged and tens of thousands of people found themselves in communities unequipped to cope with their conditions.

Medicaid – the US public health insurance system for people with limited incomes, introduced in 1965 – would not (and will not) pay for adults’ stay in mental health facilities with more than 16 beds. Those who could have turned to private establishments; others ended up incarcerated or on the streets. Prisons and prisons have become de facto psychiatric hospitals, writes Insel. A 2014 survey found that there were ten times more people with serious mental illnesses in US prisons than in state psychiatric hospitals (see go.nature.com/3kccfca).

Low investment in mental health care is not unique to the United States, and many countries released people from institutions once drugs were available. But most wealthy democracies have stronger social welfare cultures.

Insel advocates comprehensive care involving integrated teams of psychiatrists, psychologists, primary care nurses and social workers. Simply getting someone through a mental health crisis doesn’t necessarily help their long-term outlook. They need support to keep taking their medications, take care of their general health, and get their personal lives back on track.

Insel describes programs that tick many of these boxes – some in other countries (the UK, for example) and some in the US. He admires the NIMH’s Coordinated Specialty Care initiative for people experiencing their first episode of psychosis, in which specialists work together to personalize care, providing psychotherapy, medication management, family education and support, and support for the work or education. It is being rolled out across the country after promising initial results.

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

Few would disagree that politics could and should reverse the grim plight of people with mental illness. However, funding for better care should not diminish the US government’s significant investments 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 figure dwarfs similar programs in other countries.

Such generosity is needed. The patchy performance of current therapies can only be improved by a more complete understanding of the brain, which will take time. Insel makes this point but does not elaborate. He’s had his day in basic research, after all, and this book reflects his almost Damascene realization of his limitations in the face of racism, inequality, poor housing and education, and community breakdown.

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