Why America’s mental health crisis won’t be solved by new tech or drugs

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America’s silent suffering is only growing louder.?

The U.S. has faced rising rates of mental illness, substance abuse and loneliness in recent years, and the pandemic only added fuel to this fire . Suicide rates rose by 35% between 1999 and 2018 , contributing to an overall decline in life expectancy among Americans in recent years.?

Dedicating more money to mental health care, as it is today at least, may not do much. The U.S. spent more than $225 billion on mental health in 2019 .?

Instead, it’s time to rethink how we approach mental health altogether, argues psychiatrist Thomas Insel , author of the recently published “Healing: Our Path from Mental Illness to Mental Health.”?

Insel, who served as the director of the National Institute of Mental Health from 2002 to 2015, says we’ll need to move beyond the hospital and the therapist’s office to make meaningful progress. “Recovery is more than a reduction in symptoms,” he writes in “Healing.” “It is the return to a full and meaningful life.”

In a recent discussion with LinkedIn, Insel described how his thinking about mental health care has evolved and what it will take to address today’s challenges. The following conversation has been edited for clarity and length.?

LinkedIn: How would you describe the state of mental health in the U.S. today??

Thomas Insel: I have been in brain and behavior as a clinical scientist, as a basic neuroscientist, in public policy and national leadership, and then working more in the last few years on the tech side. While we have made progress in every one of those buckets — certainly in neuroscience and clinical science, and technology — we have not really bent the curve.?

For people and families with serious mental illness, they are not recovering at a higher rate. They are in some ways worse off. They're more likely to be incarcerated, more likely to be homeless, more likely to be in poverty, more likely to be unemployed than they were even when I started my career 40 some years ago. And that's a true indictment.?

What happened? What went wrong??

That's precisely why I wrote the book, because I couldn't figure that out. We now have over 30 different antidepressants, over 20 different antipsychotics, we put $5.1 billion into tech innovation for mental health just last year, which is stunning.?

Why hasn't any of that made an impact?

The care system is really broken. Many of the people who are struggling the most are not in care. And so we may create more medicines, we may create more clinics, but they aren't buying what we're selling for a whole bunch of reasons. And the sicker people are with mental illness, the less likely they are to engage.

The second piece is that even today with that huge investment in technology, a lot of that is about improving access [to mental health care], which is great. But what you need to improve outcomes is not just more access, you need better quality. And we haven't done a good job in this field around quality.

And that's actually the third issue as well: what I call accountability.

In most of medicine, where you've had that progress, like in heart disease and cancer and some other areas, a lot of that has been built on having really good measurements so that you learn as you go. Mental health is largely a data free zone.

How has your thinking about this changed in recent years?

I started this book thinking about … how technology would fix the mental healthcare system. And sort of midway through, I realized that what I'm really thinking about is mental health. It's not the same as mental health care.?

If we really care about health, or mental health, we have to think beyond health care or mental health care, because the care system maybe accounts for 10 or 20% of the variability in outcomes.?

If the care system can’t do the heavy lifting, what can?

The main things that determine what your outcomes are going to be are way outside the whole healthcare system. They're more about your zip code than your DNA code, and more about where you live, how you live, and even when and why you live, than the number of medicines or the number of clinics and doctors that you're seeing.?

So, if more doctors or drugs can’t on their own address this problem, what might?

In mental health, what we really need to focus on is recovery. I define it as three P's: people, place and purpose. If you have an illness, like schizophrenia or bipolar disorder, [treatment is about] more than a reduction in your symptoms. You need social support, you need to have a safe environment in which to recover. And you need a reason.

So many people with chronic mental illness end up losing is a reason to get better. They either end up in the criminal justice system, or they end up homeless, or in the urban single room occupancy system. They really don't have much to live for.?

Recovery says we're going to help people have a life, dignity and something that they wake up for each day, someplace to go. And we can do that. In fact, we used to do that when I first got into this field, we had very much that vision. And I think that's what's been lost.

Did the mental health research world just take a wrong turn at some point??

It's been in search of a magic bullet. It's kind of taken the model that we've used for infectious diseases, where you know, there's an antibiotic that can cure the problem; that there will be a pill for schizophrenia, or a pill for depression. And to be clear, there are pills that you can take that help aspects of those very complicated disorders. But they're not magic bullets. They help, they're necessary sometimes, but they're not sufficient for people to recover.

What is unique about mental illness that precludes that magic bullet?

These are brain disorders. The problem is medical. But the solutions have to be social, environmental, even political, there's just a whole bunch of other things we have to go after here if we want to help people recover. And I think that is because these are such complicated problems. They're rooted in all sorts of environmental issues, they’re relational problems, or things that just aren't going to be fixed simply by a higher dose of Prozac. And for years, we've sort of hoped that, but the fact is … there's no simple drug that is the cure for any of these problems.

Can therapy help??

There are very powerful effective psychological treatments for specific mental disorders. And yet there are very, very few psychological therapists who are trained to give those scientifically-based treatments. They still see the same patients, they offer them something, they tend to offer most patients the same thing because that's what they're comfortable with. There's a little bit of, they've got a hammer and everybody becomes their nail.

If you're a family member, or you're a patient coming into treatment, you'd like to think that whoever you're seeing has access to the best care available. It's just not like that.?

Is there a way to bridge this gap between the research on what works and what therapists are doing??

This was a problem in the UK as well. And 12 years ago, they undertook a massive transformation of how they trained and how they provided psychological therapies. It was largely about training 7,000 new providers in cognitive behavioral therapy, just the way it had been demonstrated to work.?

They measure everything, they measure every encounter, they look at outcomes, they look at practice. And the results show for themselves. They have now population-level improvements that are missing in the United States. If you just look at like something like suicide level, that has continually gone down in the UK, at the same time that our suicide rate mortality rate has gone up. It may not be because of [this program], but it's part of this whole story.

Now, it's not for every psychological problem. It's specifically for social anxiety and depression. But you got to start somewhere.

Is this kind of large-scale training effort feasible in the U.S., where the mental health profession is struggling with high rates of burnout and turnover?

The workforce problem is a tough one. We might need something like a Teach for America program to bring a new, diverse generation into the mental health care workforce with high quality training and a decent salary to retain them in their jobs.? Right now, our county mental health clinics are losing their workforce to Walmart.? If we value this work — and we should — we need to train people well and pay people accordingly.

In so many cases in the U.S., it’s police officers — not mental health professionals — who are the first to respond to a mental health crisis. How does this affect a person’s recovery??

Police in the criminal justice system have become the default mental health care system. That's egregious, that should be entirely unacceptable to Americans.?

We never did this when I was early in my career, the idea that you would criminalize mental illness or that people with a brain disorder would end up in jails and prisons instead of in hospitals. This is really a function of the loss of capacity. There are no public hospital beds for mental illness the way we used to have them. And we've lost a lot of our community mental health infrastructure as well.?

Twenty-five percent of people who are murdered by police are people with serious mental illness. All of this is avoidable; we don't have to do this.?

Is there a way to take police out of the equation, then??

As of July 16, 2022, every state will be required to put in a new crisis response system. It will be 988, instead of 911. It will go to a mobile crisis unit that's made up of a nurse, a social worker and potentially a peer. And they don't necessarily take people to jail. They would take them to a drop off center, like a psych emergency room or crisis stabilization unit.

In five to 10 years, we'll look back and shake our heads … that we were asking cops to be social workers. It's not fair to them as well as not fair to the public.

In the end, the most powerful solutions seem to depend less on discovering or developing new things and more about finding better ways to use what we already know or have.?

We need all the arrows in our quiver: We need to be able to provide medication when that's helpful. We need to be able to provide structured psychological treatments. What’s been missing is humaneness. We've been missing that other piece, that ability to help people with the three P's. That's really a critical part of recovery.

I want to see us take this to a point where families, no matter where they live, know that they can have their loved one recover. So that having a serious mental illness is just like having diabetes or having a broken leg. It's an episode. But once you've had a first episode of psychosis, you're not destined to have a second one. You can get over it. You can get back to work, you can finish school, you can have a family, you can have a life. That's what I'm hopeful about. We know how to do that.