Healing: Our Path from Mental Illness to Mental Health

by Thomas Insel MD

Any conversation about mental health has to navigate a linguistic landscape fraught with political, historical, and professional conflicts. Are we dealing with mental illness, mental health, mental health disorders, brain disorders, or behavioral disorders? Are these illnesses, disorders, or conditions? Is the field mental health or behavioral health? And are the people affected patients, clients, consumers, or survivors? Words matter.

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.

Behavioral disorders include addictions, from nicotine to opiates.

I recognize that for health systems and payers, “behavioral health” describes the broad area of mental illness, addiction, and sometimes wellness.

The term “mental health disorder” is one I particularly dislike. We speak of heart diseases, not “heart health disorders,” or metabolic diseases, not “metabolic health disorders.”

Are these disorders, illnesses, or conditions? I will use the terms “disorder” and “...

And I refer to people with these illnesses as patients. Psychotherapists use the term “client” and health systems refer to “consumers.”

many of the most refractory social issues of the decade—homelessness, incarceration, poverty—could be tracked in part to our nation’s failure to care for people with mental illness.

Families told me about their desperate efforts to find a place to go in an emergency, or their frustrating search to find effective care for a loved one with the kind of complex illness that an antidepressant prescription doesn’t fix.

mental illnesses are different from other illnesses. Our current approach is a disaster on many fronts.

Not only is mental health care delivered ineffectively, but it is mostly accessed during a crisis and strategically focused only on relieving symptoms and not on helping people recover.

Recovery is more than a reduction in symptoms: it is the return to a full and meaningful life.

Or, as a very wise psychiatrist working on Los Angeles’s skid row told me, “Recovery? It’s the three Ps. It’s people, place, and purpose.”

The pandemic reminded us that medical solutions were only as effective as the society that needed them.

Mental health also demands more than a medical solution.

the mental health problem is medical, but the solutions are not just medical—they are social, environmental, and political.

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.

First, although individual treatments work, they are rarely combined to provide the kind of comprehensive care that most people need.

Finally, there is the chronic, refractory challenge of negative attitudes toward treatment that keep many people who would benefit from engaging in treatment—or engaging only during a crisis.

During my career, for example, acute lymphoblastic leukemia, the most common cancer in children, shifted from 90 percent fatal to 90 percent curable.

Anyone with internet service has access to information, treatment, and supportive communities.

Health care itself explains only about 10 percent of health outcomes. The same is true for mental health.

We now understand that social factors (your zip code, not your genetic code) and lifestyle choices (how you live, not how many medications you take) are much more important for health outcomes than your specific diagnosis or health care plan. But these factors, like the factors fundamental for recovery, are often not paid for by health insurance and are usually not offered as part of care.

there are only two kinds of families in America: those who are struggling with mental illness and those who are not struggling with a mental illness yet.

Everyone who is born holds dual citizenship, in the kingdom of the well and the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later, each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place. —Susan Sontag, Illness as Metaphor

he imagines a time when Roger’s illness will be treated with the same commitment and resources that helped him bring his diabetes under control.

Mental illnesses are, in fact, major killers, not by homicide but by suicide. There are over 47,000 suicide deaths in the U.S. each year, the equivalent of a mass shooting of 129 people each day, every day.

That is a suicide every 11 minutes.

suicide as a cause of medical mortality surpasses breast cancer, pros...

At least two thirds, some would say 90 percent, of suicides result from depression, bipolar disorder, schizophrenia, or one of th...

The homicide rate has fallen nearly 50 percent since the early 1990s.

although globally the suicide rate has dropped 38 percent since the mid-1990s, in America, by contrast, it has climbed steadily, from 1999 through 2018 increasing by over 33 percent.

If we also consider drug overdoses and deaths from alcoholic liver disease, such deaths of despair became so prevalent in the U.S. by 2018 that they were driving overall U.S. life...

people with mental illness in the public health care system (i.e., on Medicaid or Medicare) died fifteen to thirty years earlier than the rest of the population.

The extent of early mortality depended on the state: people with mental illness died, on average, at age forty-nine in Arizona and age sixty in Rhode Island.

Mental illnesses are not just deadly, they are disabling. People with mental illness are currently the largest single diagnostic group of recipients under age sixty-five receiving disability support from the government.

If the twentieth century was the era of treating acute, fatal infectious diseases, most public health experts predict that the twenty-first century will be the era of addressing chronic noncommunicable diseases, like diabetes and heart disease. For these chronic disorders, disability may be more important than mortality, because people survive for years but may be unable to work or care for themselves.

NIMH estimates that about one in five U.S. adults lives with a mental illness.

Disability is defined by epidemiologists as “years of productive life lost.”

mental illness comes with a stunning price tag. Increasing costs of medications, hospitalization, and long-term care have been described as one of the greatest threats to our economy.

if we saw an increase of 12,000 deaths—the equivalent of a 747 full of people crashing every two weeks—from almost any cause, medical or otherwise, you think we would call it a crisis and respond accordingly.

People with serious mental illness feel rejected and hopeless. Hospitalization does not fix that. Community care that ensures rehabilitation takes people, time, and money. But it works.

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.

mental illnesses nearly always begin before age twenty-five, in contrast to most medical problems, which emerge in the second half of life.

While the death rates from heart disease, stroke, and most infectious diseases have plummeted, suicide death has increased.

we don’t know enough about the mechanisms or causes of mental illness to develop medications that are as effective as insulin or antibiotics.

I suspect that clinicians are helping the people they see, that they are seeing more people than ever, and that they are probably more effective today than twenty-five years ago. Why aren’t they bending the curve? The majority of people with mental illness are not in treatment, those in treatment receive little more than medications (which, as Dr. Hyman says, are not adequate), and many of the people receiving medications do not take them. This lack of treatment is one of the critical ways in which having a mental illness is different from having other medical illnesses.

So the crisis of care is not just lack of access but lack of engagement.

It’s difficult to imagine a large percentage of people with cancer or heart disease refusing to seek care. Mental illness has a different impact. Many people with schizophrenia, like Roger, do not recognize they have an illness, so they reject care.

Mental illnesses are insidious in that they frequently preclude their own treatment. And the more severe the illness, the less likely the individual will seek care. This is not to blame the person with the illness, but to recognize that the very nature of these disorders makes it more difficult to bend the curve for mental illness.