Why American Mental-Health Care Is Failing: A Restatement

Healing: Our Path from Mental Illness to Mental Health, by Thomas Insel (Penguin, 336 pages, $28)

S hortly after World War II, mental-health authorities made a promise that went something like this: Everything’s going to get better. We’ve decided that confining mentally ill Americans to asylums is unnecessary and harmful. They will be transferred to a place known as “the community.” There, we plan to develop a new array of programs superior to the discredited asylum system. The mentally ill will live normal lives in the community, thanks to supports — social, employment, recreational, housing — and access to treatment, whose efficacy is, by the way, rapidly improving. Mental health used to be “the shame of the states,” but that day is passing.

This promise was not kept, though it’s been restated countless times since it was first made. For about 70 years, American mental-health care has remained on the verge of transformation.

Dr. Thomas Insel provides another restatement in his new book Healing: Our Path from Mental Illness to Mental Health. There may be no one more qualified than Insel to assess American mental-health care’s promise. He served for 13 years as the head of the National Institute of Mental Health, a federal agency that is the world’s largest funder of mental-health research. In 2019, California governor Gavin Newsom appointed Insel to serve as that state’s “mental-health czar.” Into the bargain may be thrown Insel’s “lived experience” as the father of children who overcame mental disorders (anorexia and ADHD). Insel has a reputation as a truth-teller on fraught questions such as mental illness’s link with violence.

Healing’s main question is: Why are mental-health outcomes so poor — homelessness, suicide, incarceration — when so many input measures look so robust? Adults are using antidepressant medication at a rate two-thirds higher than they did 20 years ago. We have about 700,000 professional mental-health providers in the U.S., an all-time high. But as medical progress has, of late, advanced on many other fronts, including heart disease, strokes, diabetes, and child cancer, progress on mental health remains elusive.

Insel argues that, in principle, mental-health care is just as effective as any other form of medicine. It’s too often not done right, however, because of poor coordination and a lack of quality control. We medicate patients, which relieves their symptoms to the point where they can begin to benefit from rehabilitative services. Then we fail, systematically, to connect them with the right services. So they decompensate. We don’t need more therapists so much as better-trained ones who know how to apply proven solutions. Moreover, they need to report more about their outcomes, because as things stand now, accountability is impossible and the risks of mountebankery and mediocrity loom very large.

Insel’s reform agenda consists of subjecting therapists to more-rigorous training regimens, using brain science to improve accuracy in diagnosis, making greater use of technology to monitor the warning signs of a psychiatric crisis, reviving the ’70s-era community mental-health clinics (“Community Care 2.0”) that were intended to replace the asylums, and a reorientation away from crisis response towards prevention and recovery. Much of this program amounts to Insel promoting reforms that, while not novel, have yet to receive the commitment they deserve. Fair enough; there is nothing wrong with urging reconsideration of unjustly neglected ideas. What Healing lacks, though, in light of mental health’s long legacy of good intentions and failure, is an explanation of why readers should believe that this time it’s going to be different.

The path to authentic reform, according to Healing, runs through an appreciation of mental health’s exceptionalism. Mental illness typically begins before age 25, whereas most other medical disorders emerge in later years. Mental illness defines people who have it, because it shapes our thought and behavior (“I ‘have’ heart disease,” but “I ‘am’ bipolar or schizophrenic”); diagnoses can be wildly inconsistent; and people with mental illness, even and especially in the most severe cases, decline treatment at a disconcertingly high rate. “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.”

Insel laments much of this difference from other medical disciplines. At the same time, he notes that psychiatrists and other service providers often report having entered the mental-health field because it seems different, rich with all-too-human challenges. Insel argues, persuasively, that the seriously mentally ill need far more than medication and therapy to live a healthy life. They need meaningful daytime activities, such as part-time employment; they need rewarding relationships; they need a neighborhood to live in that’s not overwhelmed by crime, drugs, and disorder. A truly effective mental-health-care system would incorporate a commitment to “people, place, and purpose.”

But if there should be some limit on government’s responsibility to provide a sense of purpose to those who don’t have one, Insel does not go out of his way to locate that limit. A promise of adequate mental-health care, understood in that sense, looks a lot like a promise of universal happiness. If Medicaid should pay for housing, as some have argued, why shouldn’t it pay for crime control? Living in a dangerous neighborhood is far more threatening to one’s mental health than living in a safe one. What about therapy pets and platform barriers in New York’s subway to prevent psychosis-induced shovings? Should those be Medicaid-reimbursable?

At times Insel seems to back into the position that we need to solve every other social crisis first in order to solve our crisis in mental health. Insel invokes racism and “social inequities” as drivers of mental-health dysfunction. One might just as well invoke crime and drugs. Insel admires certain European cities with successful community-based systems but touches only lightly on how, unlike major American cities, those communities don’t have intractable problems with crime and drugs. Say what you will about the shortcomings of the asylum system, one thing it had going for it was that its success did not depend on the health of society as a whole. “Blaming the problem on clinicians who care for people with mental illness is like accusing field biologists of climate change.” So much for accountability.