A New Social Movement to Improve Mental Health Care – Dr. Tom Insel, Chairman of the Steinberg Institute

Dr. Rishi Desai: Hi, I'm Dr. Rishi Desai. Today, I'm honored to welcome one of the most significant national figures in the field of public health and mental health, Dr. Tom Insel. His 40-year career includes groundbreaking work in behavioral research and the use of drugs in treating mental illness, a long tenure leading the National Institute of Mental Health, and a stop at Google, where he explored the role of smartphones and how they can play a role in diagnosis and treatment—just to name a few of the many, many highlights. He's currently Chairman of the Board of the Steinberg Institute. Thank you so much for being with us.

Dr. Tom Insel: Oh, thanks, Rishi. It's a delight to be here. And I should add that part of why I'm here is, I'm kind of on a campaign to promote some non-profit work that we're doing: Both a newsletter called MindSite News, which we want anybody with an interest in mental health to sign up for, mindsitenews.org. And also a book coming out called Healing: Our Path from Mental Illness to Mental Health, which will be out in about three months. We'll be talking about some of the topics that are in that book.

Dr. Rishi Desai: Fantastic. Thank you for mentioning that. We'll definitely get to that today. To build up to how we got to the book and to the site, do you mind walking me through what got you started down your path in medicine? What got you interested in medicine in the first place?

Dr. Tom Insel: I came from a medical family. I was the youngest of four sons and my father was an eye surgeon. And in our family, there wasn't a lot of choice. My dad used to say that "you could do whatever you wanted in life, but you had to go to medical school first," because that was your basic education. 

The same way that a lot of parents say you have to finish high school, the rule in our family was you have to finish medical school, hopefully before you were 21. There was not just that expectation, but the expectation that you'd be at the top of your class and four years younger than everybody else in your class. I must say, my older three brothers I think met that expectation. I failed miserably. I was not a good student nor was I really sure that I wanted to go into medicine. I just couldn't figure out exactly what else I wanted to do.

That's where psychiatry became really attractive, and neuroscience, the study of the brain, even more attractive—this idea that we could begin to use the tools of science to understand how we think, how we feel, how we behave: I just got obsessed with that as a medical student. And I went ahead and did a residency in psychiatry, and even some clinical research in psychiatry, but pretty quickly jumped ship to become a neuroscientist. I actually spent most of my career at the bench doing some fundamental basic studies on complex social behavior, trying to understand, what are the brain pathways? What are the brain messengers that really matter for that? My lab did a lot of the original work on oxytocin and vasopressin as sort of pro-social hormones, and trying to figure out how they work and what they do.

I wouldn't recommend that path for most people who want to get into healthcare. But it was for me a matter of trying to figure out what am I most excited about? and, in any given point in my career, following my passion. And so that's how I became a neuroscientist, then later got into public service and running the NIMH at a time when they wanted a neuroscientist to be in charge of mental health.

Dr. Rishi Desai: A lot was mentioned there, especially going back about your father. You said, you have three older siblings that all went through medical school by the age of 21? Did I hear that right?

Dr. Tom Insel: I think they probably didn’t quite make it by 21, but they were young. I think they were all like 22, 23 by the time they finished.

Dr. Rishi Desai: It sounds very interesting because your father suggested, maybe in a very forced way, that you get your MD and then you choose your path. And it sounds like for yourself, you were sort of attracted to that field of medicine, anyway. Was that true of your siblings as well? I'm curious if they're all—

Dr. Tom Insel: So, we all ended up doing quite different things. Everybody went into medicine and everybody trained with a residency. Two in medicine, one in pediatrics. One brother became an academic at UCSD in pharmacology, and did basic research on g-protein receptors very successfully. He's had a spectacular career.

One got into vaccine development very early on at Harvard, and was part of the team that developed the first H-flu vaccine. Then after doing lots of different things in molecular medicine, ended up becoming lead scientist at JDRF, The Juvenile Diabetes Research Foundation. He now works for J&J.

And the third one became a real doctor. He's the only one that actually ended up practicing. He went into private practice in endocrinology. He's a spectacular clinician who loves what he does and will probably never retire, and works in Tucson where he has a very faithful following of grateful patients and has done beautiful work. We've all carved somewhat different paths, but we all have MD after our names. None of us became eye surgeons. That was probably the telling detail.

Dr. Rishi Desai: That's really funny. And it would be interesting to have a Thanksgiving with your family to see your father's reflections now that everyone's grown up.

Dr. Tom Insel: Yeah. It's always interesting. The psychiatrist in me always listens for what people don't say as much as what they do say. It is the case that I think we all compromised, to the extent that we were willing to go through the medical school requirement. But none of us were willing to actually do the ophthalmology residency, even if we could have gotten in, which was pretty hard to do in those days, right?

Dr. Rishi Desai: Your research in the '80s, as I've come to understand it, is a big part of why mental health has been on this track that it's been on. There has been more interest in using pharmaceuticals to help with many disorders. As you reflect on where we are now in 2021, what is your sense on how your research has been interpreted and used to benefit folks with these various illnesses?

Dr. Tom Insel: I did a little bit of clinical work early on, mostly trying to understand whether medicines would help people with OCD at a time when OCD—obsessive-compulsive disorder— was not considered treatable except by psychoanalysis. So this really dates me. It was really the late Pleistocene we're talking about. This is long time ago. Probably early '80s, and our work at the National Institute of Mental Health showed pretty clearly that, in fact, certain antidepressants, particularly those that block the reuptake of serotonin, seemed to be quite effective for people with obsessive-compulsive disorder.

That kind of changed the game. I don't think it was welcome news to psychoanalysts, who had a cohort of very faithful patients who continued to pay and come and never get better, which was kind of what you want in psychoanalysis. But it did provide something of value to patients. And it later did reveal that maybe not all antidepressants were the same, and that those that block serotonin reuptake might be a particularly interesting avenue for development. But I left all that long time ago.

I do think to your question, a real tension in the field has been the role of medications in the treatment of mental illness. Are we over-medicating people? Or are we under-medicating people? The data support both—that in fact there are people who get medicine that probably shouldn't. There are a lot of people who need them and would benefit from them don't get care with medication.

My own feeling about this, just to put this in a broader perspective, is that psychiatry over the last 30 or 40 years has fought hard for respect. Now the field is kind of like the Rodney Dangerfield part of medicine—like we don't get no respect here. There’s a sense from a lot of people that we're not given our due.

When I was finishing medical school, people would say, "What are you going to go into?" I would say, "I'm thinking about Psychiatry." They'd say, "Look, you got to learn the basic maxim here: “Internists know everything, do nothing. Surgeons know nothing, do everything. Psychiatrists know nothing, do nothing. And pathologists know everything, do everything, but too late." That maxim, it's not great for psychiatrists because they're people who just don't have anything to offer. 

I think what happened over these last few decades is there has been this real hunger to incorporate psychiatry into medicine, and showing that not only did we have medications that were effective, but that the medical model was the right model. These are, in fact, brain disorders and I've perhaps, as much as any, perpetrated this idea that these are brain disorders that should be treated the way we treat other medical illnesses.

I have to say, over the last four or five years, I've been much more in the frontlines of care, and looking at all the people who are not in care, and people who are homeless and in prison and jail and who are really struggling with serious mental illness. I continue to believe that there's a very important role for medicine and that the medications that have been developed for psychiatric illnesses are actually quite effective at reducing symptoms. They are in some ways comparable to what we have in the rest of medicine.

But I also believe even more strongly that we have to think beyond reducing symptoms, and we have to think beyond what medications can do, to take a much more holistic view of what people need. And what they need is what I often call the three P's: It's people, place and purpose. They need a whole bunch of things that are not part of the medical model anymore. I say “anymore” because at one point they were more part of the medical model. But this idea that we help people recover, we help them to get a life—it's about more than just reducing hallucinations and delusions or improving mood. It's about giving people the social support they need. The environment—the place they need. And the purpose—something to live for, something that they care about. That's really the essence of recovery. It's what we need to do for people with mental illness, and we're not doing that. Listen, more Prozac or more Seroquel doesn't do that. The medicines are important and they're piece of it. But in the full run of what people need to recover, they may be necessary, but they’re entirely insufficient.

Dr. Rishi Desai: To keep on that thread of people, place, and purpose, I'm thinking about smartphones. I'm a pediatrician. I have young folks coming into my office and seeing me. Almost all of them talk about the number of hours they spend on their smartphones. Everyone knows this: It's gone up.

They're not around a lot of people physically. They're not able to be with COVID, but even before that. In terms of place: I'm not sure how you define place, but I was just thinking of a physical location that is often isolated. Nowadays that's pretty much par for the course. And in terms of purpose, I think a lot of them find purpose through essentially, external validation, right? Of some sort.

I’m curious as you think about the role—not just of smartphones—but social media in general, how does that factor into the medical model, and how it's influencing these three P's as you put it.

Dr. Tom Insel: Well, I think smartphones plus COVID make all of this worse, right? As you mentioned in the introduction, I spent some time at Alphabet, or in my case it was at Verily, one of the Alphabet companies that does healthcare. I've also co-founded a series of digital mental health companies, and I'm an advisor and I work in some capacity in many of these.
So, I have a deep belief and hope that technology will help us fix some aspects of mental healthcare, particularly engagement and quality and accountability. I think those are three things that you can do really well with technology.

But I'm not naïve. I mean, I think we have to recognize that, up until now, it's likely that technology has done more damage than benefit for mental health, particularly for young people. It's not just through cyber bullying. It's this kind of toxic positivity, the lack of authenticity in interactions. There are so many aspects of social media that have become frankly toxic, and really bad for mental health. At this point, I think the challenge is getting kids off this stuff, because for so many of them it is truly an addiction, and not one that's helpful.

We've got a challenge. I like to think of this like any other technology: It's kind of a two-edged sword. You can use it for benefit. You can use for harm. We have to get really smart about how to use this for benefit. And I do think the opportunity is there—particularly around mental health. There's a lot we can do with technology to fix the problems in the mental healthcare system. But we also have to be mindful that there's a lot of damage that can be done as well.

Dr. Rishi Desai: Pulling out some of the threads you mentioned: It's addictive, you mentioned. On par, it feels like it has done more harm than good, you said. We know young people are exposed to it. 

I have a five-year-old and I'm expecting a baby on the way. What do you tell parents when they're thinking about the fact that these addictive, more-harm-than-good devices are available ubiquitously? Schools use them, as you know. What advice do you have for young parents who are thinking, "Gosh, I don't want my kid vaping. I don't want my kid abusing drugs. And maybe I don't want my kid using this other class of devices that experts are saying does more harm than good on net, and is addictive?" What do you tell them?

Dr. Tom Insel: We went through the same thing when I was a kid around television, right? The whole thing was that television was going to warp our minds and shrink our brains, and all that. In some ways, this is not that different. I think the message is not so much, "don't use," but be mindful about what they're used for. I mean, it's hopeless to try to get kids to stay off the internet. That's not going to happen. It might happen with a 5-year-old. It's not gonna happen with a 15-year-old, I guarantee you. Or a 12-year-old, especially like my grandson, who does a really good job of helping me navigate the internet, especially new social media sites.

I'm actually more concerned about parents’ use of technology. I can't tell you, because I now spend a lot of time with young kids, how often I'm at a playground or a pool or someplace where there are parents and kids around, and the parents are locked into their phones, and the kids are just out of sight, out of mind. That worries me as much as whatever the kids are doing on their technology. 

This is one of those transformative technologies, and we have got to figure our way through this. I often say that we're in the first chapter of a five-chapter book, or maybe the first act of a five-act play. And I don't think we've quite figured it out. I think we're now becoming aware of some of the threats and some of the harms, and I think all of us are perfectly aware, if we use Amazon Prime, or we use Google to look stuff up—we're aware of the benefits. Those aren't going away.

We aren't going to give this up. But figuring out how to balance those, and ensure that we're getting something of value without being addicted, and without losing control over this. And there are companies that are actually trying to think this through for us. If you go to a black and white screen, does that help? What if you put caps on the time, so you have automatic off-time? Are their ways of scheduling around it? and putting, for kids, limits on what they see and how they see it?

There's a bunch of things that people are thinking about to help us manage this, rather than being managed by it. But we're not there yet. And I do have concerns in terms of kids who are growing up with this, what is it going to do to their mental health, in terms of being able to operate in real life and interact with people in a way that is healthy and authentic.

Dr. Rishi Desai: That makes sense. And I've definitely seen what you're talking about with parents just completely glued to their phones. It's really ironic because I think a lot of us bring our kids to playgrounds to learn how to socialize. It feels like the kids are doing a pretty darn good job of it, and that the parents are actually pretty antisocial—not in the psych sense—but in the sense of not really talking to one another or commingling or demonstrating that virtue that we're sending our kids off to learn.

Dr. Tom Insel: Isn't that interesting. That's right. And of course the kids pick that up. We're modeling this behavior for them, especially when we don't notice it.

Dr. Rishi Desai: At the outset you talked about a book. I love to dive into that—just to understand the impetus for writing it. Who do you imagine the intended audience for the book to be? And what might they draw from the book that that might benefit their life?

Dr. Tom Insel: Thanks for asking. The book was like a lot of projects: I took it on to try to understand something I couldn't understand. The conundrum for me was I was looking around and I saw all this enormous progress in Neuroscience and Genomics, in Psychological Sciences. I saw this huge progress in research and science. And I saw more people were getting more treatments than ever before. And yet the outcomes were no better. 

I just couldn't square those dots. I couldn't make sense of it. I was trying to figure out, what have we done wrong? Why is mortality going up? There's suicide. Why is morbidity going up? More people are homeless, more people disabled, especially with serious mental illness. It just didn't make sense to me. And I remember when I started in this field, almost 50 years ago, we did better. People did better even though we had fewer drugs and fewer things to offer.

I started the book to say, "Okay, I bet there are some easy fixes here." Originally, I thought, well, since I was in the tech sector, that tech was the answer. I quickly convinced myself that it was maybe part of the answer. It can help us on some issues. But the problems were much more fundamental.

It was really around this issue of recovery. I began to realize that part of why we hadn't done better was that we were aiming for the wrong target. We were trying to reduce symptoms, instead of helping people to get a life. We bought into this idea that mental illness was like an infectious disease—that it was caused by a simple bug, and it could be cured by a simple drug. 

It's not. It's more complicated. These are in fact, brain disorders, and I ended up saying that the problem is in fact medical. It's a medical problem and it ought to be paid for by insurance like any other medical problems. 

But the solutions are much more than that. The solutions are social, relational. The solutions are environmental. So that's person, place, and purpose. And the solutions are also political. It needs a whole new social movement.

The book ends up being a call for a social movement around mental health, and that was actually the genesis of MindSite News as well—the idea that we need a platform, a place for this national conversation to take place about how we have failed those with mental illness in so many ways.

President Kennedy talked about this in 1963 when he launched the Community Mental Health Act. He said, “these people should no longer be alien to our affections.” For a few years in the 1960s and 1970s, they were not. We actually invested, and we built out community programs and we trained people with the skills to actually help those with mental illness.

Then all that faded away. We closed the state hospitals. There was no longer capacity for people who needed in-patient care. They ended up in jails or prisons, or they ended up in homeless shelters, or on the street. We fail to be able to provide good medical care for these folks, so they die 23 years before they should. And they became one of the most neglected populations in our society, more than any racial or ethnic group.

This is a group that, in a sense… we're sort of in the Jim Crow era for mental health. These people are not even in care. They're not even on the bus at all. And so, the book really is calling out the need for us to notice and to respond, and to provide care more than medicine, but to provide the whole range of healthcare. And then those things that today are not even included in healthcare, like people, place and purpose.

We know how to do this. This is not a research problem. It's a compassion problem. It's a commitment problem. It's a political problem. And that's really what the book was written to do, and what I hope MindSite News will help us to do. And what I hope podcast like this will help to do is to raise awareness that we have really failed those people who are struggling with an entirely treatable disorder. We haven't provided that kind of care that we should have, and our grandchildren are going to ask us: “How is that even possible that people with schizophrenia were just locked up in jail instead of treated in clinics? How could you have lived through that and allowed that to happen?” 

That's really what drove the book, ultimately. I was trying to make sure that we wake up to this problem and begin to do something about it.

Dr. Rishi Desai: I've been really struck, like you said, by this moral obligation, or this feeling of like, how could you possibly stand by and watch this happen? Many cities across America right now are seeing homelessness on the rise and are seeing opiate overdoses on the rise. There are so many classic problems that are blowing up. I think there's a moral framework around a lot of those things. There's also a medical framework around those things. And you proposed this medical framework. 

I'm curious because you said that there is a political aspect to it. Do you feel like there's been some level of polarization around that? Do you feel there's any pushback on that idea, and people saying “no, no. Folks that are out there are out there for a reason. They have to get their act together. They have to hit rock bottom before...” You've heard all these phrases, I know that. I'm just curious to see if you get a lot of pushback, and if that push back feels like it's coming from individuals, or if there's a political pushback as well?

Dr. Tom Insel: It's a good question Rishi. I don't get a lot of pushback. I think there's real frustration with the homeless crisis because it's been just so hard to solve, and people seem to think that we ought to be able to do better on this. And I think their right... I'll say more about that in a moment. 

But our question actually reminds me about how we talk a lot about the social determinants of health. But I think there's this new term, of the moral determinants of health, which is equally compelling. If you haven't had Don Berwick on the podcast, I highly recommend you talk to Don about the moral determinants. He's written about that. To me it's been a very powerful construct, and one that I think is important for mental health as well.

I don't get a lot of pushback around these issues. I must say, I think they are bipartisan. When you talk to politicians about mental health issues, you discover pretty quickly that everybody's got a story. Every family has been affected. In my years in Washington, I had some of the most conservative Republicans as supportive as the most progressive Democrats. In fact, in some cases, even more supportive based on their personal experience. Most people, they get it. Just a couple of weeks ago, a very liberal member of the Senate, Bennett and a very conservative member of the Senate, Cornyn, did a white paper together, saying, "We've got to start paying attention to mental health.” It's not a partisan issue, as they said in their report. It's a personal issue.

I do think that time has come. You have to be careful, I think, not to frame it in partisan or political terms, even though I said that there's a political aspect of this. But I think it's political in the old sense: It's about policies. It's about saying we are going to pay for things that work. We are going to ensure that there is parity, which is a policy, for mental health and substance abuse as well as all medical illnesses. 

I think yes, there's that important focus on policy. But it's probably best not to create a partisan divide around this, because right now, there isn't one. Right now, this is one of the few areas in America that I think does enjoy bipartisan support.

Dr. Rishi Desai: That's a fantastic point. And probably one that makes it stand out as a place to start working together on something that's positive. As we close, I'd love to get your advice. We have a lot of folks in the audience that are interested in a career in health care, maybe pushed along by their own fathers, or their own volition. What's some advice on how they can meet the challenges of the moment? You mentioned act one out of five acts—things are going to shift and change as we go forward. How do we remain nimble and able to adapt to the change that's forthcoming?

Dr. Tom Insel: I don't know if there's a simple answer to that. My advice usually is to go with what you're most passionate about, and I think if you look around and you say, "Where can I have the biggest impact?" my deep belief is you have the biggest impact by going where the need is greatest. 

The need is greatest in communities of color, communities that are poor, often rural communities. Especially in the United States. Native American communities. We're talking about tens of millions of people who are really outside of the bubble that we built to provide quality care.

I would add to that, and not just because you're the other end of this conversation, but I really think that it's critically important for people to think about the needs of kids. The United States has done actually a pretty good job in caring for its elderly. It’s not great, but if you just compare where we were 50 years ago to where we are now, we do better with Medicare, Social Security, all of that.

We put a whole bunch of stuff in place for people over 65. For people under the age of 5, not so much. We are probably the lowest of all developed countries in the investments we make, the policies that we have, the way we respond to the needs of kids and families. That again is one of those areas that we should find unacceptable.

I think for a person coming into the field, that's an opportunity to really change the world of young kids and families, to make sure that they're getting the policies, the care, and to use the Kennedy phrase, that they're “no longer alien to our affections"—that they are really getting the kind of support in the United States that they would get in any other developed country. It's shameful that we haven't done better. And I would love to see the next generation take that on and fix it the way my generation did for people over 65.

Dr. Rishi Desai: Thanks for that plug. I couldn't agree more both in terms of health as well as education. Do you mind, before we go, doing one quick last shout out for the site, the book, where folks can find that information?

Dr. Tom Insel: You bet: www.mindsitenews.org. And please, it's free. Signup. Contribute. We're looking for lived experience. We're looking for the voices of everyone, anywhere, about what they care about related to mental health.

And then there’s the book, which won't be out until February 1, but you can pre-order it from Penguin Random House: It’s called Healing: Our Path from Mental Illness to Mental Health. Please pre-order. The more we can pre-order, the more attention it will get from the reviewers, and from everybody else. This is a book that is really meant to start a movement, and we need to get a lot of people engaged.

Dr. Rishi Desai: Thank you. I just went to the website and it looks awesome. Congrats on that. Thank you so much for being with us today. That's fantastic.

Dr. Tom Insel: My pleasure. Thanks for having me, and good luck with this podcast. I know there are a lot of podcasts out there, but I love the fact that you're doing this for people who care about health.

Dr. Rishi Desai: Thank you. I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.