A new book by Dr. Thomas P. Insel, who for 13 years ran the United States’ foremost mental health research institution, begins with a sort of confession.
During his tenure as the “nation’s psychiatrist,” he helped allocate $20 billion in federal funds and sharply shifted the focus of the National Institute of Mental Health away from behavioral research and toward neuroscience and genetics.
“I should have been able to help us bend the curves for death and disability,” Dr. Insel writes. “But I didn’t.”
Dr. Insel, 70 years old, has left N.I.M.H. in 2015, calls the advances in neuroscience of the last 20 years “spectacular” — but in the very first pages of his new book, he says that, for the most part, they haven’t yet benefited patients.
His book, “Healing: Our Path From Mental Illness to Mental Health,” is not an indictment of the science to which he devoted much of his adult life. It instead chronicles the failures of virtually every other aspect of our mental health system. This includes ineffective care delivery and reliance on jails and police for crisis services.
It also highlights a paradox: The United States, which leads the world in medical research spending, is also known for its poor outcomes with people with mental illness. In fact, these outcomes have declined over the past three decades despite the fact that the government has spent billions of dollars to better understand the brain.
The country’s long spell without breakthrough treatments can be attributed, in part, to the complexity of the brain.
Dr. Insel rose through the ranks at a time of optimism that advances in neurobiology would lead to new treatments, and as head of N.I.M.H., as he put it, he “bet big on genomics.” But 20 years later, he said the role that genes play in schizophrenia and bipolar disorder has proven to be extraordinarily complex.
“Each of those variants that have been discovered just account for a tiny, tiny amount of risk, so in aggregate, they’re probably significant, but you have to put a hundred of them together,” he said. “So we started doing bigger and bigger studies to find smaller and smaller effects.”
In an interview, he said he didn’t regret making genetic research a priority — “at the time, how could you not?” he said — but he acknowledged that the diminishing returns nagged at him.
“I don’t think focusing on finding these very small effect signals for common diseases, I mean — it’s not how I want to spend my time, I’ll put it this way,” he said. He added, “I realized, wow, I mean, we could continue doing research until I’m in my 90s, but if we can’t get this stuff actually implemented, if people aren’t doing it, what’s the point?”
In the book, he describes an “epiphany” during his last year at N.I.M.H., after he had delivered a PowerPoint presentation to a group of advocates, touting researchers’ progress on genetic markers.
A man in a flannel shirt got to his feet and reeled off the story of his 23-year-old son, who has schizophrenia — a cycle of hospitalizations, suicide attempts and homelessness. “Our house is on fire,” the man said, “and you are talking about the chemistry of the paint. What are you doing to put out this fire?”
“In that moment, I knew he was right,” Dr. Insel writes. “Nothing my colleagues and I were doing addressed the ever-increasing urgency or magnitude of the suffering millions of Americans were living through — and dying from.”
‘An exciting intellectual adventure’
If Dr. Insel’s statements have attracted attention, it is in large part because they are coming from one of the most influential neuroscientists of our time.
Dr. Insel was the director of N.I.M.H. and a champion for basic research. He believed that understanding genes would unlock some of the most difficult mental disorders.
He steered the agency’s $1.3 billion research budget toward the biology of disease. This was criticized by some in the field who suggested that the funding should have been split more evenly between neuroscience, clinical research, and treatments that could be used in near future.
Dr. Allen Frances, a professor emeritus of psychiatry at Duke University School of Medicine, warned in 2014 that the institute was “betting the house on the long shot that neuroscience will come up with answers to help people with serious mental illness.”
Last week, Dr. Frances, who is 79, stated that his warnings were true.
“The end result of these last 30 years is an exciting intellectual adventure, one of the more fascinating pieces of science in our lifetimes, but it hasn’t helped a single patient,” he said.
He said that it was difficult to be proud of his 55-years of experience in the field, seeing the number of homeless camps in so many American cities. People with severe mental illnesses, he said, were “much better off” then than now.
“I have a happy life, and I’m not spending every minute of my life feeling guilty, but if I look back on my career, it’s with regret, not with satisfaction,” he said.
Dr. Insel sees things differently. He doesn’t regret his work nor criticize his successor at N.I.M.H, Dr. Joshua A. Gordon. He is, however, an advocate for basic research. If anything, Dr. Insel said, the country should “double down on brain research.”
The country’s mental health crisis is “not a research problem, it’s an implementation problem,” he said. He stated that good treatments for serious illnesses like schizophrenia or bipolar disorder are already available and it is not the task of scientists at N.I.M.H. to provide services.
“It has nothing to do with what they do,” he said. “It’s asking for French food from an Italian restaurant.”
His comments still caused some problems at the agency he managed.
In an interview, Dr. Gordon, the current director of N.I.M.H., said Dr. Insel had failed to acknowledge “some really wonderful things that were done at N.I.M.H.” during his tenure or “the tremendous work that we continue to do in research that had short-term impacts on mental health care.”
He gave two examples of new treatments based on neurobiological research: ketamine to treat treatment-resistant depression and Brexanolone to treat postpartum depression. The N.I.M.H. has funded other studies that have resulted in treatments being used today, including a large-scale research that demonstrated the effectiveness and efficiency of comprehensive services for people experiencing psychosis for the first time.
He said that it takes decades to realize the big breakthroughs. Dr. Gordon was in graduate school when scientists cloned the gene for Huntington’s disease, and only now, three decades later, has that work led to new, effective treatments. To envisage breakthrough treatments in the short term, he said, was “bravado.”
Definitive treatments for autism, bipolar disorder and schizophrenia based on genetics are “not likely to pan out in the next five or 10 years,” he said. But researchers have identified hundreds of relevant genes and are “starting to understand the function of those genes in the context of the brain,” which could, he said, provide a pathway to better therapies.
“Could this be the same bravado?” he said. “I’m not using a date.”
Dr. Insel believes he is in a different position now than Al Gore, who after serving as vice president and senator reinvented his self as a truth-teller about climate change.
He hopes “Healing” serves a similar purpose as “An Inconvenient Truth,” the documentary film about Mr. Gore’s efforts, sounding an alarm to the country.
“I want to ring the bell to tell people that we can do so much better today, and there is no excuse for allowing people with these brain disorders to languish on our streets like this and die at age 55, eating out of trash bins,” he said.
And though he supports the work of the army of researchers he once led, “at my age,” he said, “I can’t wait 30 years.”