Why the Path to Mental Health Goes Beyond Science: America’s Former Top Mental Health Leader Explains

Thomas Insel

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Marianne O’Hare : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter. In observance of National Mental Health Month this
week we welcome Dr. Thomas Insel , former Director of the National
Institute on Mental Health and au thor of the new book calling for an
overhaul of America's mental health system.

Dr. Thomas Insel: People with these disorders, more than with most medical disorders ,
can recover, and they do recover if they're given appropriate care.

Marianne O’Hare : We ’ll hear from FactCheck.org Managing Editor Lori Robertson and
we end with a bright idea , improving health and well being in
everyday lives. Now, here are your hosts Mark Masselli and Margaret
Flinter.

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Mar k Masselli: One in 20 US adults experienced se rious mental illness each year.
That's what the government's statistics tell us. Our guest wants to
understand how we can do a better job helping some of our most
vulnerable.

Margaret Flinter: Dr. Thomas Insel led the National Institute of Mental Health fo r 13
years and his new book Healing : Our Path f rom Mental Illness to
Mental Health is now available.

Mark Masselli: Well, thank you for joining us, Dr. Insel. Just to set the stage, here's
what we know about mental health in our country during the
pandemic , anxiety increased 50% depression was up 44% and those
rates were about 20 points higher for those ages 18 to 29. Do you
think greater incidence of mental health issues will or can result in
more understanding and support? I s there any such thing as a sil ver
lining in all of these pandemic related issues that we've been facing?

Dr. Thomas Insel: Well first Mark, thanks for having me. I do think as you say that there
is a potential silver lining here, it's the case that this pandemic has
been particularly d ifficult for mental health for young people. If you
just look at the numbers, people under 30, we've lost about 7000
people to COVID in the last two years in a few months . We've lost
about 70,00 0 to deaths of despair from mental illness in the same age
gro up . It is without question been a rough go for those particularly
young people who have been more affected by the psychological
consequences of COVID than by the infectious disease itself.

That said, I think it has brought a lot of attention to a problem t hat
was there before the pandemic, an d it's also helped us to understand
that we're going to have to approach it with different approaches. It’s
not going to be the old brick and mortar 50 minute hour, but it's the
opportunity to innovate. U sing t elehealth and using a lot of new

Thomas Insel

programs that have been developed by entrepreneurs a chance to
actually improve access and increased quality for people with mental
illness.

Margaret Flinter: Dr. I nsel during your time leading the National Institute for Mental
Heal th, you oversaw $20 billion in federal funds, we ’d like to say here
in Connecticut $20 billion is about the size of the entire annual budget
for the state of Connecticut. But in this federal role, you made a
critical decision to shift i nstitute funding tow ards the neuroscience
and genetics of area more and away from the behavioral research.
Share with us a little bit about the strategy of this move. What was
compelling that directional shift for you?

Dr. Thomas Insel: Yeah, so it's important to remember tha t NIMH is the science agency.
We have other agencies in the federal government that respond to
services and are really accountable for service delivery. But the NIMH
and broadly the NIH role is to chase after the very best science and to
support the best s cience to answer those questions, giving us kind of
new understanding of the biology and the psychology of these
illnesses. I had a fantastic opportunity , observed a great time. I think
it's still a great time, but the science was really developing in thos e
areas you mentioned, in the areas of neuroscience, genomics . A lso I
would say in behavioral science and cognitive science, we ha d just
entirely new frontiers, new tools , and a whole new generation of
people who are asking very compelling questions about schizophrenia
and bipolar illness and depression and PTSD.

It’s an extraordinary period of time for research to really begin to
reframe the problem , help us to understand that these were really
problems of brain circuitry, brain connectivity, and would pot entially
open up new ways of trying to treat and ultimately even cure some of
the problems at hand. It's clearly far more complicated than any of us
would have bargained for in 2002. I think when I left in 2015 it was
with the pride that we made a lot of p rogress. Problems always ended
up being more complicated than you expect at the beginning often,
and it will take more time more investment.

I left not because I was disappointed in the science or anything but I
was still really fire up by the science. But it's clear that there was a
need for services for implementing the science that we had already
developed that whole industry that had said we know how to help
people recover. Y et, those insights weren't being used by the service
sector , s o it wasn't any s ort of regret or disappointment with what
NIMH had done. It was really the need to say, how are we going to be
able to help people recover? That's not an NIMH problem , it’s not a
scientific problem. We have the science to help us there. It's a
problem of i mplementation. It's a problem of service delivery, it's a
problem of actually providing the incentives and paying people for the

Thomas Insel

things that work.

Mark Masselli: Yeah, let me just pull the thread on that. You say that mental illness is
a medical problem, y et the solutions seem to be social,
environmental, and politica l, or at least elements of them. It seems
that's going to be a tough sell to get buy - in from many sectors,
because we have a bias that if you're sick you take a pill and that
should solve the p roblem. Fixing society is much harder.

Dr. Thomas Insel: Well, that's really why I wrote the book, because I agree with you. I
mean, if we need to resolve racism before we begin to reduce suicide ,
it's going to be a tough climb. We're working on this for d ecades , a nd
so we have to thin k much more I think strategically about what can
we do . I lay out what I call the recovery model of three P's, People
Place a nd Purpose , a nd it turns out that we actually have solutions
hiding in plain sight for each of those . We have clubhouses which are
not expensive, which are able to give people the social support the
job training, actually the sense of purpose as well, so they can actually
begin to recover. We have what we call assertive community
treatment teams or ACT te ams that proactively engage people to
make sure they get the kinds of access they need.

We have what we need in that realm of rehab ilitative or recovery
services, an d in fact we do pay for those on the medical side . Y ou
break your leg, you get to go into a six months of rehab, physical
therapy, all that will be paid for by insurance, but you have a
psychotic break, and you're going to need 6 to 9 to 12 months of
rehabilitative support that's going to be paid for by some charity
that's holding a bake sale to make sure you have access to some social
support. M aybe you'll even get some job training if you happen to be
really, really lucky. But h ealthcare doesn't pay for that.

Th e point of the book was to say, just as with a broken leg you've got
a broken brain, you need the same kinds of services it needs. It's not
enough to just provide medication in an emergency room and send
somebody home . You need to make a commitment. This is a long
process if you want someone to heal, which is why the book i s called
Healin g. It's about this whole process of People , Place and Purpose ,
and building that in for someone over a long enough time to let them
really get back to a state of private.

Margaret Flinter: Well, I think that there's been a good response to the fact that
Pr esident Biden has put forward a number of mental health initiatives
focused on expanding access a nd services. We've certainly seen a big
focus on reaching kids in schools, for instance, for behavioral health,
and the National Alliance on Mental Illness has called it an
unprecedented focus on mental health when he gave the State of the
Union address, and yet I think seared in the eyes of people around the
country are the sights of homeless people with mental illness on the

Thomas Insel

streets in so many of our major cit ies, and still so much work to be
done. If President Biden were here with us, what advice would you
give him on what still needs to happen from a national perspective?

Dr. Thomas Insel: That's a great question. The first thing I would say is b ravo. I think we
haven't had leadership on this problem in 41 years . President Carter
was the last one to really focus at all on the national crisis around
mental health. I t's only gotten worse since, much worse. Now I look at
that unity agenda that the White House put out on the day of the
State of the Union , I was pretty excited because it conforms almost
exactly to what I wrote in the book. It's almost all the same points and
I was delighted to see that. I was also a little worried. I was worried
that we maybe haven' t learned all of the lessons from the 1960s and
70s. W hat happened with the Community Mental Health Act that
President Kennedy launched in 1963 was we built these community
mental health centers around the country with federal dollars. They
didn't integrat e with state and local programs , a nd so when they were
defunded, there's no backup. There was no safety net beyond the
c ommunity mental health centers. We need to make sure we don't do
that again.

As we think about th e -- in some ways, a good way to think about this
is it's a balance of federal support, state and local support. W hat we
need is to weave those together seamlessly. But I'm concerned about
this now that federal support, federal leadership is coming back in
literally for the first time in four d ecades , we need to make sure that
it's not supplanting the work, but it's synergizing with the work that's
already being done and also being proposed in states like California,
so that we've got federal local state partnerships to provide the care
that peo ple need. That's the mistake that I think we made in the
1970s .

Mark Masselli: I want to sort of get back to that sort of concept of a local social
movement being needed and you write about this , right , in terms of
mental health. I wonder if we don't have that already . We certainly
have elements of it , we have celebrities and polit icians who share
their struggle . W e've had former Congressman Patrick Kennedy on
our show . W e've also recently had Jane Pauley on talking about the
issues and advocacies. But what do you think is missing from this
larger public dialogue? Can that top end leadership be sustained
without a real strong grassroots effort , a nd what's your assessment of
where we stand in terms of that level of social engagement?

Dr. Thomas Insel: I think the message that we've had so far from my perspective are not
quite the right message . I think the message that we hear a lot about
is kind of, it's okay to talk about it, it's kind of an ant i - stigma message .
I don’t actually think t hat's useful. In fact, I don't like the term stigma.
It's a victim term, it doesn't lead to change and I personally have been

Thomas Insel

involved with anti - stigma campaigns for decades, and stigma has only
gotten worse. Let's bring this as discrimination. It's not stigma . It's
actually so mething that's in some ways more insidious and more
difficult. T he piece of that, that I think needs to really be honed as a
message needs to be conveyed very clearly to the public, and
somehow has been so overlooked is that these treatments really
work, n ot just medication, but psychological interventions, these
rehabilitative treatments, they really work . People with these
disorders more than with cancer, more than with heart disease, more
than with mos t medical disorders can recover, and t hey do recover if
they're given appropriate care. T he real tragedy here isn't that we're
stigmatizing them , i t's that we have great stuff to offer that we're not
giving them even though it's hiding in plain sight , a nd so I think that
message that peop le can recover is re ally lost.

There was a wonderful headline in the New York Times , it said,
“D ementia is where my mother lives it’s not who she is. ” That's
actually exactly the right message here. Schizophrenia is where some
people live, but it's not who they are , a nd so we need to treat that
illness so those people can actually thrive. We know how to do that
and we're not doing it and that's the tragedy. I think that's a piece of
it. But I would agree with you that we do need more of a social
movement that comes from below as well , a nd that means
empowering families to demand the kind of care that works. It’s
outrageous that families take their adolescent to an emergency room,
and they're told that they have to wait 9 days or 12 days for a bed ,
a nd so their 17 year old is ch ained to a gurney day and night for 12
days in the back of an emergency room. T hat is happening every day
across A merica. That is not acceptable.

It’s time for families to begin to say to people who represent them,
we're not going to put up with this . I sa y in the book that we're sort of
in Jim Crow era of mental health care. I mean, this is just outrageously
unjust. It's unethical. It's a painful immorality in this country , a nd yet
people are not yet talking about it. There's no reckoning with this kind
of an injustice . U ntil people are faced with it themselves and then
they're so overwhelmed t hey can't tell they can do to manage that, let
alone become advocates for social change. It’s going to take an effort .
I've used the proceeds of the book to launch Mi nd Site News , which is
a platform it's a new digital publication to sort of lift up this issue and
help people to understand just (a) how unjust it is and (b) how fixable
it is. Unlike climate change, we can do this immediately. We know
what to do. We're ju st not doing it , a nd that's the piece that really
needs to be made -- where people need to be more clearly aware of
that in the public dialogue.

Margaret Flinter: Well, Dr. Insel, that is a very powerful story how many teens spend
their nights in the emerg ency room just waiting for a bed to open up . I

Thomas Insel

have to wonder Governor Gavin Newsom appointed you as the
mental health leader for California. Whether you think that this is a
moment in the country's history when these issues around mental
health and public policy, government and services, transcends
partisanship , t here isn't a family in America that probably hasn't been
touched by behavioral health issues. Do you think this is a time when
you can really make great strides in a bipartisan way?

Dr. Thomas Ins el: When I look what the governor's done in California, it's pretty
extraordinary , I mean, some really big programs and big commitments
and it is inspiring . I think you’re onto something. I think this is an area
that is more personal than political , a nd I do think that it is absolutely
bipartisan in the sense that leadership of both parties in the Federal
Congress have decided that this is an important area for them to try
to effect some kind of change. I'm pretty hopeful. I think that the
pandemic that one of the , maybe unexpected silver linings here was
that it's made this an issue that we can all now begin to talk about,
because we have to .

T o your point, I say in the book, there are really only two kinds of
families in America, they're the families who a re struggling with a
mental health issue and the families who are not yet but they will ,
a nd so we all become involuntary e xperts here. We all end up
whether it's spouse, or parent or child, all of us, every family,
eventually is faced with having to figur e out how to help a loved one.
O ur job is to make that easier, not harder.

Mark Masselli: I want to go back to earlier part of the conversation you started
talking about the sort of force multiplier of technology. Y ou're also
just mentioning your evidence based in terms of how you look at this
and even though i ts evidence based, it's not necessarily fully yet
embraced in the public's mind. But walk through some of the
technology that you see out there, you're excited about you had
spent some time at Google working with startups, obviously, we're
seeing a lot coming out of Silicon Valley to make more accessible
mental health services .

R ight now we're in a community health center. Our population is cost
conscious, this old model that somehow I have to leave my 7 - Eleven
job, take two buses, waiting your waiting room for an hour to be seen
for 15 minutes just seems to be antiquated . But walk through not only
that the value of t elehealth but what are you seeing in some of these
very interesting, very exciting, yet I'm not sure researched enough
startups that are going on in the behavioral health space?

Dr. Thomas Insel: Yeah, thanks for asking Mark . I mean, I think the conversation about
technology and mental health often centers on apps, is there going to
be a cha tbot for depression ? I s there maybe some virtual reality
software and hardware that can fix phobias ? T here are some

Thomas Insel

interesting things there. But I think what we've seen in this last couple
of years, is the enormous value of being able to access care onlin e s o
people moving from the brick and mortar to being able to use Zoom
or some interface that allows you to find therapists or find care and
even find medication at your convenience, not at the convenience of
when the clinics open, or meaning that you have to leave your job and
drive for an hour, or take two buses to get there. That's great. I think
you've already seen this . We've got companies like Mira [PH] and
Cerebro [PH] and Modern [PH] and Big Health [PH] that are all very
valuable and they're providi ng care to literally tens of thousands and
actually hundreds of thousands of people who might not have been
getting care before. Y eah, this is a pretty interesting way of improving
access through increased convenience, kind o f like what Amazon
does, right .

It's not clear that it's improving quality or improving outcomes. I think
the next stage of this innovative revolution that we're on is going to
be how do we ensure that people are not only getting access, but
getting access to what works and getting bett er as a result and that
means measuring. W e have to start to bake in measurement. I call
that t elehealth 2.0 s o that becomes part of every interaction. T he
same way with your diabetes or your hypertension you manage it
through getting actually outcomes tha t you work to work towards.
We're not fully doing that in the mental health space, but we could
and we will. I think if act, one was getting some of the major players
so we could see who they were goin g to be getting access improved,
act two is going to be improving quality through measurement.

Margaret Flinter: Well, I'd like to maybe following up on that give you just a moment to
talk about 988 the three digit dialing code that will route callers to the
National Suicide Prevention Lifeline beginning in Ju ly. What do you
want people to know and share with their friends and neighbors
about 988?

Dr. Thomas Insel: Well s o we have a new line, it's not going to be a 10 digit n umber, but
a three digit number. Three things I would say. One is that 988 is not
911 , right . 911 is just a dispatch service. 988, if it's done right can be a
t elehealth service. It's a place where you can go in real time like
within minutes, either through phone, chat or text, to be able to
connect with somebody who has the skills to either direct you to care
or to provide care. I f it's done really well, unlike 911 they'll call you
back the next day to make sure that's working , s o that's the first thing
that 988 is something quite different than what we've been thinking
about for emergency s ervices in the past, particularly in the 911
space.

Second thing to remember is it's just a phone number, right. F or a lot
of people it's going to require more than just to call . Some people are

Thomas Insel

going to require someone to come , s o you need mobile vans to go
with that. S ome of those people are going to need some place to go ,
s o you need to have psych emergency rooms or crisis s tabilization
units, all of that. We don't want people going to jail . We don't want
them go into a medical surgical emergency room un less they
absolutely have to. W e have to build out that whole continuum , a nd
that's not going to happen right away, which is my third point.

The third point is it took about a decade to get 911 , right . It's going to
take us some time to get 988 to actually solve the problems that it
was set up for. T he problem we have now is tragic interactions with
police, people ending up in jail or incarcerated instead of in health
care, and the crowding in of our emergency rooms. Those three things
th
are not going to get solved on July 16 when the new number goes in
place, but it's the beginning of solving those problems. G ive us some
time, it's going to take a while to build out that continuum. But we
know if we put in the continuum of care we can actually see some
pret ty good results in terms of fewer interactions, tragic interactions
with the police department, fewer use of jails as the kind of default
mental health system, and not so much crowding in the emergency
rooms.

Mark Masselli: Thank you so much Dr. Insel. The New York Time calls you one of the
most influential neuroscientist of our time, and it certainly easy to
understand why. Thank you also to our audience for joining us. You
can learn more about Conversations on Health Care and can sign up
for our email upd ates at www.chcradio.com .

Dr. Thomas Insel: Thanks for having me.

Margaret Flinter: Thank you so much.

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Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about healthcare reform and
policy. Lori Robertson is an award winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US p olitics. Lori,
what have you got for us this week?

Lori Robertson: A leaked draft opinion indicated that the Supreme Court is ready to
abolish the 1973 Roe v . Wade decision establishing a constitutional
right to abortion. The draft written by Justice Samuel Alito is
authenti c. The High Court said in a statement noting that circulating
draft opinions was a routine part of the court ’ s work and that this one
didn't represent the final position of any justice. But what happen ed if
the court does overrule Roe. Jurisdiction would g o back to the s tates
likely setting up a patchwork of abortion restrictions and rights across

Thomas Insel

the country. Roe v . Wade established that states couldn't limit
abortion before a fetus is viable or able to survive outside the womb,
which is generally consider ed to be at about 24 weeks of gestation.
But state laws have sought to challenge the point of viability .

The Center for Reproductive R ights and A dvocacy and legal groups
supporting abortion rights brands 25 states as hostile to abortion
rights, saying they would be likely to prohibit or severely restrict
abortion. The Guttmacher Institute a reproductive health research
group counts 26 states as certain or likely to ban abortion under all or
most circumstances or early in the gestation period, such as aborti ons
after six weeks of pregnancy. Among those states are nine that have
pre Roe abortion ban s on the books that could take effect if Roe is
ove rturned, and 13 states have passed so called trigger laws after Roe
to ban abortion if Roe was abolished.

On the other side of the debate 16 states in the District of Columbia
have laws protecting the right to an abortion. A decade ago only
seven states had such laws on the books, but more state legislatures
have been taking up the issue in anticipation of a possible reversal of
Roe v. Wade. New Jersey Governor Phil Murphy, for example, signed
a law In January that permits abortions throughout pregnancy. In
some states, including Alaska and Minnesota, the right to an abortion
is protected not by law, but by their stat e constitutions. I n a few
others, there are not legal protections for abortion rights, but the
states also aren't likely to restrict or ban abortion. T hat's my fact
check for this week. I'm Lori Robertson, Managing Editor of
FactCheck.org.

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Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com , we'll have
FactCheck.org's Lori Robertson check it out for you here on Conversations on Health Care.

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Mark Masselli: Each week Conversations highlights a bright idea about how to make wellness a part of our communities and everyday lives. Anxiety
disorders are on the rise among the nation's youth and experts in the field of child psychology feel the condition starts much earlier in
childhood, and it's far more common than previously thought with an
es timated one in five children being affected . But too often these so
called internalizing disorders go undiagnosed. Unlike children with more expressive conditions such as ADHD, young kids struggling with anxiety or depression may just seem like an in trover t to the casual

Thomas Insel

observer.

University of Vermont Child Psychologist Ellen McGinnis says the
process of diagnosis for younger children is often painstaking and can
take months to confirm. Dr. McGinnis says the traditional method of
diagnosis involves creatin g scenarios that induce anxiety, followed by
behavioral observation by clinicians, and the results can be inexact.
She teamed up with her husband and fellow researcher biomedical
engineer Ryan McGinnis to create a wearable sensor that can pick up
on physic al cues that suggest the presence of anxiety, using
accelerometers and simple algorithms to c ompare normal stress
responses.

Dr. Ellen McGinnis: The device is called Inertial Measurement Unit, and it's about the size
of a business card a nd so we strap that to belts on each child. W hen
they did the mood induction task it has an accelerometer in it a nd so
we were able to pick up angular velocity, speed, how much the child is
bending forward and backward, and turning side to side, and it
actually picks up 100 samples per second, so much more than the eye
can see. W e were able to see if kids with anxiety and depression move
differently in response to potential threatening information , a nd they
do. K ids with disorder turn further away from the potential threat
th an kids without a disorder.

Mark Masselli: Their research paper shows the device was nearly 85% accurate in
making a correct diagnosis. S he says early diagnosis is the key to
avoiding more damaging manifestatio ns of anxiety disorder later on.
A simple wear able tool that can assist in determining if a child is
suffering from anxiety disorder, leading to more rapid diagnosis and
treatment , now that's a bright idea.

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Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli .

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and Health

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Marianne O’Hare : Conversations on Health Care is recorded at WESU at Wesleyan
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