Reinventing Mental Healthcare: Dr. Thomas Insel on the Path to Heal our Failing System

Dr. Thomas R. Insel M.D. is a neuroscientist, psychiatrist and national leader in mental health research, policy, and technology. He was the director of the National Institute of Mental Health (NIMH) for 13 years, where he oversaw billions in federal funds researching mental disorders and developing tools and treatment for them. But after 15 years as “the “nation’s psychiatrist”, he felt something was off. Why, with so much scientific progress, were the realities of mental health – addiction, suicide, homelessness and many others – still so pronounced?

He traveled the nation talking to healthcare innovators, entrepreneurs, and frontline mental health professionals in a quest to find solutions to our failing mental health system He published his findings in his new book, “Healing: Our Path from Mental Illness to Mental Health.”

To me, Tom has been a generous mentor and a good friend, and I’ve learned much of what I know about the mental health system through our conversations. As a matter of fact, much of Cerebral’s clinical strategy is based on Tom’s insights on quality and measurement-based care. He serves as an engaged member of our advisory board. Rarely do we have a figure in medicine whose experience traverses so many domains: research, regulatory, public health, entrepreneurship, investing. I talked with him recently about his journey, his fantastic new book, and what he believes are the answers to our spiraling mental health crisis.

How did you get into mental health care?

I’ve had a long and diverse career in mental health care. I trained in psychiatry during the era of psychoanalysis, during which I worked in research in both the clinic side and in basic science. Later I led the National Institute of Mental Health and teams at various technology companies.

But even during all that time, what’s striking is how little has changed for clinical care when so much has changed in research and technology. In fact, in some ways, we gave better care in 1972 than we do today. Back then, we did not incarcerate people for having psychosis. We didn’t have so many people with mental illness becoming homeless, and we had a functioning public hospital system where people could go for weeks or months to recover.

It was far from ideal, but in the 1970s as a young psychiatrist working in the community mental health system, I had a kind of pride, optimism, and accountability for my patients. I don’t see many people with that today.

You describe an “epiphany” that made you rethink mental health. What happened?

I was in Oregon giving a presentation to a packed room of people, many of whom were family members of young people with a serious mental illness. I clicked through my PowerPoint of high-resolution scans of brain changes in people with depression, stem cells from children with schizophrenia showing abnormal branching of neurons, and epigenetic changes as markers of stress in laboratory mice. Look at these slides! It’s proof we had learned so much and were making progress, right?

I could see a tall, bearded man in a flannel shirt in the back. He looked agitated. And when we opened it up for questions, he jumped to the microphone. “You really don’t get it,” he said. “My 23-year-old son has schizophrenia. He has been hospitalized five times, made three suicide attempts, and now he’s homeless. Our house is on fire, and you are talking about the chemistry of the paint. What are you doing to put out this fire?”

I stood there somewhat dumbstruck and was defensive at first. “Science is a marathon, not a sprint,” I said. “We need to know more before we can do better. Be patient; revolutions take time.”

But I knew he was right. There was a disconnect between supporting brilliant scientists and dedicated clinicians – and the challenges 14 million Americans living and dying with serious mental illnesses faced every day. That’s when I started trying to understand why – with so much progress in neuroscience and behavioral science – we’ve seen so little progress in outcomes for people with serious mental illness. It just doesn’t make sense.

What are the major causes of this disconnect?

Our mental health care system is broken. It’s not working for patients, families, providers, and payers. I think there are three major reasons for this:

Lack of engagement. Engagement is a bigger problem in mental health than most areas of medicine. In fact, the more someone with a mental illness needs care, the less likely they are to seek it.

Lack of quality. It’s often during a crisis when someone seeks care. Then they face exactly what they don’t need: Delays, chaos, a system anything but user-friendly. We have great treatments, but many providers aren’t trained to deliver them. Too many providers also focus on what they know how to do and not what people need.

Lack of accountability. We don’t measure outcomes in mental health. And as the business saying goes, “We can’t improve what we don’t measure.” Without objective, standard measurements, we can’t learn or improve.

But it’s not just that the system is broken. It’s also that the social safety net for people with the highest needs is shredded. Incarceration and homelessness are the symptoms of a profound illness in the soul of our nation – something that will not be fixed by more medication and more clinical visits. This is why I titled my book “Healing” because I want to shine a light on this injustice and the need for all of us to participate in creating a better world for those with brain disorders.

So how can we do better?

We’ve been following a specific model for mental health for the past several decades. Like the medical approach to an infectious disease, it’s to define a problem through a diagnosis and provide medication to fix it. This hasn’t worked as well for people with mental illness as it has for people with infectious diseases.

An alternative to this is a recovery model. I came across this when talking to a psychiatrist in Los Angeles’s Skid Row. It’s a radical alternative that focuses not only on the relief of symptoms, but also helping someone build a life. In the book, I talk about this model as the three P’s: people, place, and purpose. That means finding people for support, having a place or sanctuary to heal, and discovering a purpose or mission. Each of these is essential for building a life after, for example, a psychotic episode, a severe depression, or a bout of anorexia nervosa.

We typically don’t focus on the three P’s in our current care system, and we don’t pay for the 3 P’s with insurance. So although I still think the medical model is essential – we need to address mental illnesses with the same rigor, standards, and reimbursement we use for any serious medical problem – we can’t address this as another medical problem, and the solutions must include people, place, and purpose.

In addition, there are two workstreams we need to focus on. One is fixing the care system using high tech and high touch. This will help, but it will not be enough. The second one is fixing our social safety net so we no longer criminalize mental illness, and we don’t allow people with serious mental illness to die homeless and neglected on our streets.

Are today’s mental health treatments ineffective?

One of the most common misconceptions about mental illness is we don’t have good treatments. Our treatments are not easy, but they are effective, and there are many of them. For example, medications control symptoms, psychological interventions confer skills that allow mastery, new neuromodulatory treatments like Transcranial Magnetic Stimulation can help when other modalities aren’t effective, and recovery-based services like supported employment and supportive housing help people thrive.

Not all these treatments are available, and not all are covered by insurance. But the good news is we have them, and they work. The problem, which is a solvable one, is making sure people get access to the treatments that do work.

It’s also important to remember that mental health is not just about mental health care. Providers like to think they are critical to better outcomes. They are important, but outcomes are determined more by how you live, where you live, who you live with, and what you live for than by the number of medications or clinic visits you have.

Is access or quality of care more important?

We need both. This first phase of innovation in mental health has been mostly about improving access, increasing convenience, and affording more choice. Those are all important. But to improve outcomes, we also need to raise the bar on quality. Better access to crappy treatment is not progress.

How do we solve the limited availability of services?

One of the promises of the digital mental health revolution is that we can democratize care, allowing someone in Botswana and someone in Boston to receive the same treatment from the same provider. That’s amazing. But the shortage of providers is going to remain a problem unless we get creative about closing the supply-demand gap.

One option is to move to chat bots, which could automate therapy. The jury is still out on whether or when that will suffice. Another option is task sharing, using coaches instead of providers with graduate degrees. Task sharing has already proven effective in the developing world. (Granted, in terms of mental health, I consider the U.S. a developing nation.) A third option, which is central to my most recent company Humanest Care, is to empower people to help each other. We don’t think about this in the health care system because we have a hierarchical structure built around the professional. But at Humanest, we’ve found there is nothing more therapeutic than giving someone a chance to help someone else.

How else can technology play a part?

Of all areas in medicine, mental health will be transformed the most by digital innovation. These are early days, but we can already see how technology can begin to close the engagement gap, the quality gap, and the accountability gap.

Tech companies know how to solve for engagement. In fact, social media companies may be too good at this, which can lead to addiction. But we should learn from their use of consumer-centered design to better understand how to engage people in their care. For quality, better care coordination, data science, enhanced workforce training, and upskilling with online courses and supervision can help. And accountability is fundamental to technology through continual data collection and feedback to improve performance.

Virtual care will continue to play a part, too. The use of telehealth has been one of the few silver linings of the pandemic. Who would have thought health care could change so quickly and so completely? We won’t return to a full brick and mortar world, and telehealth is not ideal for everyone or every problem. So we’re headed for a hybrid care system. It will mostly be virtual, but with some in-person care.

Regardless, any company wanting to use technology will have to be disciplined in their approach to truly make a difference. That’s one thing that’s impressed me about Cerebral. I don’t know any other company that’s grown so quickly yet stayed so focused on doing a few things well. It’s amazing to me that a company just a little over two years old has already become one of the largest providers of mental health care. The potential to improve quality and change outcomes is almost unprecedented because Cerebral has this scale. It’s likely possible to build a learning engine so Cerebral not only provides the best standard of care, but eventually can improve the standard of care. I can’t wait to see how that will unfold.

What do you plan to do next?

want to spark a new social movement that would ensure, in President Kennedy’s words, that people with mental illness “no longer be alien to our affections.” My book is a call to action and, I hope, the roadmap for this movement. And it doesn’t stop there. The advance from the book also funded a non-profit mental health publishing site named MindSite News. I’m hopeful Cerebral and other innovative companies will join us as we build advocacy for new policies, new resources, and a new commitment to healing, especially for people who have truly been “alien to our affections.”

Thank you Dr. Insel for the interview and insight. Be sure to check out his new book for a blueprint on how to improve the future of mental health care.