Poor US Mental Health Care Confirmed From a Top Authority

Dr. Thomas Insel’s new book makes poor mental health care a human rights issue.

 

A similar version of this post was published earlier in Psychology Today.

A momentous event for the mental health field occurred with publication of Dr. Thomas Insel’s new book: Healing: Our Path from Mental Illness to Mental Health (2022).1 His severe condemnation of present mental health care cannot help but shake the very foundation of the field, especially when he avers that present care is so bad that it flouts basic human rights. Why should it have such an impact when most already recognize the shambles that mental health represents in this country? Dr. Insel is the highly respected former Director of the National Institute of Mental Health (NIMH), the federal agency most responsible for mental care in America.

National Institute of Mental Health: official picture of Thomas R. Insel, Director, National Institute of Mental Health, as provided by the NIMH Office of the Director—CC-PD-Mark; PD US Government

While addressing all mental health care, he finds the worst injustice in serious mental illnesses, such as schizophrenia and bipolar disorder. Poor care for these patients usually is seen as stemming from “de-institutionalization” (from mental institutions) in the mid-20th century. Dr. Insel better captures the problem: serious mental illnesses underwent “trans-institutionalization.” The patients did not go into the communities as planned. They went to jail and/or became homeless, care almost completely unavailable. And it’s not just their poor mental health care. They die, on average, about 25 years earlier than other patients, often from the common ravages of heart disease, hypertension, and cancer. Why? They don’t receive medical care either.

In spite of the dramatic advances in neuroscience research, where NIMH is at the vanguard, Dr. Insel was troubled by persisting poor mental health care at all levels. This led him to branch out and seek patients’ assessments of the problem. He tells us of his surprise, for example, saying, “I heard this refrain throughout: mental health care is broken, our house is on fire, we are indeed in a crisis—a crisis of care.”

Ironies pervade the book, for example, stunning scientific progress has not translated to patients, mental health care is delivered to patients only in crisis (rather than as ongoing care), and—most striking—treatments work but they are not delivered to patients.

After a compelling diagnosis of the crisis in mental health care, Dr. Insel, in my opinion, stumbles in advising on how to correct it. Surprisingly, given his espousal of a greatly widened biopsychosocial approach, particularly for expanded environmental and social care, he retains the reductionistic stance that mental disorders are fundamentally brain diseases. He recognizes that none have been found to explain mental illness but insists we just need more research and more time to find the putative explanatory diseases.1,2 He does offer some hope for psychiatry’s almost exclusive focus on finding brain diseases in reviewing that 30% of patients with autism spectrum disorder have some genomic basis.

Regarding the manpower needed to correct the actual day-to-day care problem for Americans, Dr. Insel’s approach is uneven. He makes a good start in recognizing the severe shortage of psychiatry practitioners. Indeed, for psychiatry’s most proven clinical approach over the last 25 years, collaborative care, he is quite honest, “…it required a workforce that did not exist.” He points out that a total of only 41,740 psychiatrists exist at present. But he makes a strange turn and proposes that the mental health workforce is large enough. Yet, the data he provides indicate a severe deficiency of mental health workers capable of frontline care: there is a combined total of only 143,630 psychologists, psychiatrists, psychiatric nurse practitioners, and child psychiatrists. That’s nearly an order of magnitude short of what we need to provide primary mental health care for over 300,000,000 Americans. Dr. Insel correctly notes that another 549,330 mental healthcare workers exist, but they are not trained for frontline mental health care, for example, licensed clinical social workers, marriage and family therapists, licensed mental health counselors, and school counselors.

We thus have a severe shortfall in trained frontline mental health workers. Making the problem worse, as I’ve noted before in these blogs and as Dr. Insel also emphasizes, the result is that primary care clinicians conduct most mental health care in the US, in the range of 75% of it.3-5 But they lack training in mental health care.

These problems aside, the book has launched a figurative tsunami by highlighting poor US mental health care as a human rights issue. And there’s another reason to read the book: patients’ stories of their severe mental illnesses will tug at your heart strings. The reader comes away with a true appreciation of their plight and for what’s needed for successful care—long-term community-based care. Further, Dr. Insel’s sharing his own empathic responses not only to the patients but also to family members tells the reader he is truly a man who cares, someone to listen to.

All told, this book is a must-read for patients, health care professionals, policy makers, tax payers, and everyone else interested in mental health care, now magnified by COVID-19.

KEY POINTS

1. One of America’s top mental health leaders condemns present mental health care.

2. Care for the seriously mental ill is particularly a peril.

3. Modern mental health care flouts human rights.

Copyright Robert C. Smith March 19, 2022

REFERENCES

1. Insel TR. Healing–Our Path from Mental Illness to Mental Health: Penguin Press; 2022.

2. Insel TR. Balancing Immediate Needs with Future Innovation. Director’s Blog. Bethesda, MD: NIMH; 2012.

3. Wang P, Demler O, Olfson M, Pincus HA, Wells KB, Kessler R. Changing profiles of service sectors used for mental health care in the United States. AmJ Psychiatry 2006;163:1187-98.

4. Melek S, Norris D. Chronic Conditions and Comorbid Psychological Disorders. Seattle, WA: Millman 2008.

5. Kathol R, Sargent S, Melek S, Sacks L, Patel K. Non-traditional Mental Health and Substance use Disorder Services as a Core Part of Health in CINs and ACOs. In: Yale K, Raskauskas T, Bohn J, Konschak C, eds. Clinical Integration — Population Health and Accountable Care. 3 ed. Virginia Beach, VA: Convergent Publishing, LLC, 4445 Corporation Lane, Ste 227; 2015.

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