Healing: Our Path from Mental Illness to Mental Health

by Thomas Insel MD

In the U.S., mental health care for the century after 1860 meant a state hospital system, consisting of asylums that nationwide housed nearly six hundred thousand people with mental illness by 1955.

Kennedy’s 1963 Special Message to Congress was the first and last time a U.S. president focused so extensively and exclusively on mental health care. Eunice Kennedy reportedly spent six hours reviewing and editing a draft of this speech.

The total cost to the taxpayers is over $2.4 billion a year in direct public outlays for services.

Mostly we apply metaphors from the current state of technology: in the first half of the twentieth century we described hydraulic models because metaphorically the brain was an engine; in the second half of the twentieth century the brain became a chemical soup with thousands of newly discovered interacting molecules; and today it is, of course, a circuit-based information-processing machine like a computer.

Yup

we can monitor behavior, which is the brain’s output;

Let’s begin by looking at four broad categories: medications, psychological therapies, neurotherapeutics, and rehabilitative services.

Today there are about thirty different antidepressants, twenty different antipsychotic drugs, seven different mood stabilizers used in bipolar disorder, and six different classes of drugs for ADHD.

Between 2015 and 2018, 13 percent of Americans over the age of eighteen were prescribed an antidepressant in the previous month, an increase of 65 percent from two decades ago.

A 2014 report from the CDC (based on parent surveys and not pharmacy data) estimated that 5.2 percent of U.S. children between the ages of two and seventeen are taking stimulants, like Ritalin, for ADHD.

“When medication works, the world does its bit. Patients are freed to notice what’s precious in their lives. That’s why doctors prescribe.”

People are frequently hospitalized for suicidal risk when they are first evaluated for depression. But the highest risk actually comes later, when, like Sophia, they are beginning to improve. In the depths of depression, Sophia was unable to formulate or execute a plan.

Dr. Jacobs added duloxetine, another antidepressant, to the fluoxetine, reasoning that duloxetine, which targets norepinephrine

In general, medications that target norepinephrine are more stimulating, although they sometimes add to anxiety and restlessness.

And he wanted her seen more often, to make sure that someone was watching for a drop in her mood or a rise in her risk of suicide.

For many people over fifty, psychotherapy is still synonymous with psychoanalysis.

This process, which analysts call transference, is the essence of psychoanalysis.

Although helpful for personal growth, psychoanalysis is not by itself a treatment for mental illness. It is categorically different from the modern psychotherapies that have been developed in the past four decades.

modern psychotherapies provide a very direct line to master specific skills, like reframing problems into opportunities and taming emotions with mindfulness.

These modern approaches focus on specific behavioral or cognitive targets where skill learning is the basis of change. For instance, behavior therapy for obsessive-compulsive disorder (OCD) was specifically developed for avoidance behavior (using exposure and response prevention). Someone with a germ phobia would learn to tolerate germs by touching public toilets or rubbing their hands on the soles of their shoes while refraining from handwashing.

Dialectical behavior therapy was developed to help patients with borderline personality disorder manage the volatility of their emotions.

Dr. Jacobs knew that over three decades of rigorous research have shown that CBT reduces the primary symptoms of depression, especially when the depression is of mild or moderate severity.

This approach, while psychological, can also fit with the biological view of leveraging brain plasticity to change neural connections.

As the global mental health pioneer Vikram Patel said recently, “If we could bottle psychotherapy and deliver it as a pill, it would be the best-selling drug in the world.”

Many therapists still rely on psychodynamic psychotherapy, an approach that is closer to psychoanalysis.

Dr. Jacobs raised the possibility of regional transcranial magnetic stimulation (rTMS).

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.

ECT established the concept that electrical stimulation via a mechanism that is completely unclear can reverse depression.

A more popular approach has been regional transcranial magnetic stimulation (rTMS), which can be delivered without anesthesia and does not elicit a seizure. First approved by the FDA in 2008 for treatment of refractory depression, rTMS has become the first widely disseminated stimulation-based treatment for depression.

But the name has served a purpose by recognizing that some people need more than medications and psychotherapy. It is patients with treatment-refractory depression, like Sophia, who are referred for rTMS treatment.

In addition to ECT and rTMS, teams of psychiatrists and neurosurgeons have pioneered an invasive treatment with deep brain stimulation activating specific circuits. Neurosurgeons implant electrodes to record from and stimulate deep structures in the brain.

While deep brain stimulation has been used in over 150,000 patients with Parkinson’s disease and other neurologic disorders,

This research demonstrates that depression can be targeted as an arrhythmia—changing a discrete circuit can lift the symptoms of hopelessness and despair. Indeed, people who have had this stimulation describe immediate relief, even while still on the operating table.

How did rTMS help Sophia to, as she said, “find her way back”? Our best understanding is that repetitively activating the surface of the brain changes the pathways beneath. We call this neuromodulation. In the same way that direct surgical stimulation of the deep prefrontal cortex can lead to immediate relief, scientists think that repeated activation of the surface can train the circuits that need to reboot during depression.

for Sophia and many patients like her, neurotherapeutics helped to end despair.

Psychotherapies, especially targeted behavioral and cognitive treatments, work, but not everyone is well enough or motivated sufficiently to undertake this approach.

Sophia identify exactly what kind of role she wanted when returning to the workforce after four years. With the employment specialist she talked about her lack of confidence and her anxiety about returning to work, just like an athlete returning after being sidelined from a bad injury. This is what rehabilitative care looks

20 percent showed persistent symptoms, suggesting that these mood disorders even when treated well are more chronic than episodic. Sophia indeed recovered, but she felt she was still not 100 percent three months after finishing her rTMS protocol.

Few providers are able to integrate medication, psychotherapy, devices, and rehabilitative services to maximize the likelihood of recovery.

It is hardly surprising that providers do not offer rehabilitative services if no one will pay for them.

But these factors don’t really explain the central question we need to answer. If current treatments are so good, why are outcomes generally so bad?

It is easier to get your kid into Harvard Medical School than to find a psychiatric bed in the state system. —Dr. Ken Duckworth, acting commissioner of mental health and medical director for the Department of Mental Health of Massachusetts, 2003

“If my son had been in distress from any other medical condition, a diabetic coma or cardiac collapse, would he have been sent home untreated from the emergency room?”

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.

Thus, federal policies ensured that the 90 percent reduction of beds in state institutions could not be replaced by federally funded mental health care facilities with beds.

Psychiatric beds are low-reimbursement beds in a general hospital, bringing in less than one fourth the income per square foot of an orthopedic center or a cardiac unit.

the licensing requirements force any hospital that wants to serve psychiatric patients to build rooms free of sharp edges or protrusions that could be a hanging risk. Hospitals have to modify faucets, toilets, door handles, ceiling tiles, and fire sprinklers at a national cost of over $2 billion each year. In addition to the potential liabilities of housing psychotic and suicidal patients adjacent to medical or surgical patients, there is little economic incentive to have mental health care in a general hospital.

The biggest drop has been in public beds—that is, hospital beds for people without private insurance or wealth. Currently there are 12.6 public beds per 100,000 people, down from 337.0 beds per 100,000 people in the mid-1950s, a reduction of well over 95 percent.

A 2016 survey found that in four states (Arizona, Iowa, Minnesota, and Vermont), fewer than five state hospital beds remained per 100,000 people. What’s the right number? In most of the developed world, the average is 71 beds, as represented by the Organisation for Economic Co-operation and Development (OECD) countries. Most health policy experts estimate that the U.S. needs between 40 and 60 beds per 100,000, which is at least four times higher than the current U.S. public bed count.

Unlike the asylums of the late nineteenth century that were built in remote areas, Fremont Hospital sits in the middle of downtown Fremont, California, on a broad, tree-lined street near a large medical center and busy upscale strip malls.

private facilities like Fremont Hospital run about 15 percent below capacity.