Healing: Our Path from Mental Illness to Mental Health

by Thomas Insel MD

I appreciate these disorders originate in the brain, but the term “brain disorder” connotes an irreversible lesion. Mood, anxiety, and psychotic disorders involve a dysregulation of brain activity, perhaps a disorder of connectivity or a “brain arrhythmia,” but not (yet) an identifiable lesion. And relative to some neurodegenerative disorders, people can recover from mental disorders. On the other hand, “brain disorder” accurately conveys the serious nature of the problem. There is a risk that the term “mental disorder” means a mild or moderate condition that is neither deadly nor disabling.

“We are not going to fix the mental health care system, because in America there is no mental health care system to fix.” Dr. Carmona was right, and his answer still rings true: we do not have a mental health care system. 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 was built by insurance companies and pharmaceutical companies, and, to a limited extent, providers. It was not built by or for patients or families or communities. Dr. Carmona understood that “the fix” was not simply a new policy or a new medicine; it demanded a rethinking of the problem and a refocus on solutions that moved from crisis care and hospitalization to prevention and recovery.

I had thought that our biggest problem was access to care, yet there are nearly seven hundred thousand mental health care providers, more than almost any other medical specialty. I had thought that we needed a new generation of treatments, but current treatments are as effective as some of the most widely used medications in medicine. I had thought that if we provided much better care we would see better outcomes, but outcomes depend on much more than health care.

Blaming the problem on clinicians who care for people with mental illness is like accusing field biologists of climate change.

when I left medical school in the 1970s, the prevailing attitude was captured in a popular description of the four career options: internists know everything and do nothing, surgeons know nothing and do everything, psychiatrists know nothing and do nothing, and pathologists know everything and do everything but too late.

People with mental illness should therefore be treated in the same health care facilities and covered by the same insurance with equivalent benefits, a mandate that in law is known as parity. I still argue for inclusion and parity, but I think we need to admit that Roger’s problem differs from most medical illnesses in several critical ways.

We provided much more than medications at the Berkshire Medical Center: we followed patients intensively, we had a stepped approach to help people following hospitalization, and we saw people recover. In a word, we were accountable. Whether the person was at home, in school, in our clinic, or in the state hospital, we were responsible for their care. Patients didn’t fall through the cracks because there were no cracks: care was not fragmented.

My experience at the Berkshire Medical Center may be as good as it ever got. In most of the country, deinstitutionalization was already a disaster: chronically ill people who had adapted to life in an institution were completely unprepared for life in the community, and the integrated supports they needed didn’t materialize. Community clinics, usually staffed by professionals interested in psychoanalysis for people with mild or moderate mental illness, were unwilling or unprepared to care for the people who had been hospitalized for years.

In 1982, the funds from the Community Mental Health Act were shifted to a Mental Health Block Grant routed through state mental health departments. By statute, block grant funding could not be used for hospital costs, a legacy of deinstitutionalization. Between the reduction in funding and the loss of services, people with serious mental illness, already underserved, increasingly were left without care. For anyone living with SMI, there was no longer a humane public mental health program for long-term care. By this time, as advocate Torrey describes it, “all authority and responsibility for the mental illness treatment system had essentially disappeared. Authority that had previously been vested in state legislatures, departments of mental health, and governors had become so diffused that it seemed to evaporate altogether. . . . The mental illness treatment system had been essentially beheaded.”

The government pivot away from state hospitals cost that population two decades of life, on average. In dismantling the earlier flawed system, we created a new crisis.

Electroconvulsive therapy (ECT) was the original version of changing brain activity via electrical stimulation. The approach, which induces a seizure across the full cortex in an anesthetized patient, might be akin to rebooting a computer. Of course, ECT, first introduced in 1938, preceded the modern era of medications and psychological treatments and certainly preceded the computer age. But I have never heard a better explanation for how ECT works than this metaphor of rebooting.

This is what rehabilitative care looks like. Research shows that this sort of ongoing supportive care is critical to prevent relapse, with long-term effects that equal or surpass the impact of medications. And yet this suite of interventions is generally not available to most people with SMI. Unlike physical therapy, the range of rehabilitative services following a psychotic episode or depression are usually not covered by insurance. No reimbursement unfortunately means no access to a trained workforce.

Why are there so few beds? Deinstitutionalization created a legal legacy that still today blocks funds for psychiatric hospitalization. As we know, the 1963 Community Mental Health Act was about reducing the hospitalization of patients as the federal government developed a community mental health care system. And with the Medicaid Institutions for Mental Diseases (IMD) exclusion, written into the Medicaid Act of 1965, Medicaid funding for care of an adult in any mental health facility having more than sixteen mental health beds was, and still is, prohibited.

The rooms are spare, clean, and safe, with beds built in as solid platforms and open cubbies for personal possessions. Each unit displays handsome photographs that match the scenic theme, soothing images of Shasta at sunrise or the Monterey coast at sunset, rendered onto metal, bolted securely to the wall. Each unit has an isolation room, but according to the staff, isolation or mechanical restraints are rarely required. Unlike a medical-surgical hospital, patients are not in their beds. There are group meetings, physical fitness activities, and meals outside of their sleeping rooms. Compared to the incessant beeping and paging and bustle of a medical unit, psychiatric units are quiet, even peaceful. And if you expected the wards to be overflowing because of the urgent need for psychiatric beds, you’d be surprised that private facilities like Fremont Hospital run about 15 percent below capacity.

And in perhaps the greatest irony, parents in some jurisdictions have been told that their mentally ill children will need to commit a crime to receive mental health care.

But homelessness is much more complicated than our stereotypes of drifters and misfits. Some of the homeless are families living in their car; some of the homeless move in and out of shelters; others spend years living under a bridge or in an encampment. Each of these versions of homelessness is by itself stressful, dangerous, and unhealthy. Add mental illness to this mix, either as a cause or a consequence, and you have a modern tragedy.

As Oakland attracted tech companies and upper-class tenants from Silicon Valley, rents skyrocketed along with home values.

A nod to the constrained housing supply would be appropriate.

Duane is not alone. His brother-in-law and an uncle are living in tents across the street. In fact, most of the people on this stretch of Martin Luther King Avenue have grown up in Oakland and known one another for years. They have a community, watching one another’s possessions so that one at a time they can use the restroom or get a meal at St. Vincent de Paul’s around the corner.

But even as a professional in this space, I found it difficult to navigate the maze of care. The first issue is that there are so many different types of professionals: social workers, marriage and family counselors, clinical psychologists, professional psychologists, psychiatrists—and they all call themselves therapists.

For problems like anorexia nervosa or obsessive-compulsive disorder, for which specific psychological therapies have been proven to be effective, there may be only a few hundred trained therapists across the country.

Most people who teach psychotherapy deliver what they learned in training, and for many, this was determined not by scientific evidence but by what worked for a few charismatic clinicians. In contrast to evidence-based care, I call this “eminence-based care.”

If this humanistic approach was working, there would be no reason to change it. But the evidence sadly calls for a more accountable effort. In an era with standard treatments of proven effectiveness, should we allow therapists to pursue their passion, treating everything as a nail because they have a hammer? Can we, in good conscience, look at the growing death and disability rates and argue for “more art than science”?

One surprising result is that many of the genomic risk factors for schizophrenia show up in people with bipolar disorder. Either nature did not read any of the standard psychiatric textbooks or the genomics of mental illness are broad-based, conferring risk for developmental brain disorders rather than specifying a cluster of symptoms.

the most important insight thus far to emerge from psychiatric genomics is not the discovery of a mutation, but a new view of mental illness: these disorders increasingly look like developmental brain disorders.

The emergence of depression and anxiety may be determined, even more than these highly heritable disorders, by adverse events in childhood. While adverse events do not change the genomic code, they clearly alter the epigenomic code.

This is not to say that fear and avoidance are necessarily irrational. Mental health advocates and antistigma campaigners may not want to hear this, but the data are clear. People with untreated mental illness are more likely to be irrational, disruptive, and, yes, violent than people without SMI. Usually that violence is self-directed, leading to suicide or self-injury. And the data are equally compelling that people treated for a mental illness are not more likely to be violent than those without mental illness.

he learned that honoring these wishes could be an error of omission. A homeless woman who rejected care for two and a half years by screaming at the outreach team when they approached was finally committed for involuntary treatment when she became threatening. Three years later, O’Connell saw her at a board meeting of a nonprofit organization. Finding her totally transformed, O’Connell remarked, “You look fabulous.” Her response, “Screw you. You left me out there for all those years and didn’t help.”

It is important to realize that the choice between individual liberties and public safety can be a false dichotomy. Often the choice is not between individual rights and public safety but between an individual’s illness and personal safety.

“Connection is critical, but it’s not just these strong, safety net kinds of ties. It’s also weak ties. The mail person you see each day or the water-cooler folks in the workplace. These relationships, while not deep, are also sustaining and critical for well-being.”

The lessons from Collaborative Specialty Care, the Health Home, and the Friendship Bench are clear. As Francis Peabody, a famously compassionate Harvard Medical School professor said in 1927, “The secret of the care of the patient is in caring for the patient.” As with so many problems in mental health, the solutions are not complicated. And as these examples show, they are not expensive. I sometimes feel that if you wanted to design the most expensive, least efficient, truly feckless approach to helping people with mental illness, you would probably start with emergency rooms, criminal justice, and repeated short-term hospitalizations. You would shift care to the most expensive providers. You would have your least trained, unpaid workforce address your most acute needs on crisis hotlines. And you would make sure that families and peers were left out. Sound familiar?

There are three versions of prevention. Primary prevention, such as a seat belt or a vaccine, reduces risk in the entire population. Secondary prevention, such as a lipid-lowering drug, is for people with a known risk factor such as high cholesterol and a family history of coronary artery disease. And tertiary prevention, such as aspirin following a heart attack, prevents an adverse outcome after onset of an illness. Tertiary prevention is what we find today in mental health care.

People with mental illness are more likely to be incarcerated, homeless, destitute, because they are the most vulnerable in a world that no longer has a social safety net.

When I started this journey to resolve the mental health crisis, I believed that technology and science would provide the answers we need. A new drug, a killer app, a breakthrough would make the difference.

Echoes of energy and transportation.