From the New York Times February 22, 2022.
The ‘Nation’s Psychiatrist’ Takes Stock, With Frustration
In a new book, Thomas Insel, who led research into psychiatric disease for 13 years, says that advances in neuroscience have yet to benefit patients.
Credit…Carolyn Fong for The New York Times
By Ellen Barry
Feb. 22, 2022
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, who 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. Instead, it chronicles failures in virtually every other element of our mental health system, including the ineffective delivery of care, the gutting of community health services and the reliance on police and jails for crisis services.
It also calls out a paradox: that the United States, a country that leads the world in spending on medical research, also stands out for its dismal outcomes in people with mental illnesses. Indeed, over the last three decades, even as the government invested billions of dollars in better understanding the brain, by some measures, those outcomes have deteriorated.
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’
Dr. Insel, with his dog, Teddy, near his home in Pleasanton, Calif. He now sees his role as sounding the alarm for America about mental illness.
Dr. Insel, with his dog, Teddy, near his home in Pleasanton, Calif. He now sees his role as sounding the alarm for America about mental illness.Credit…Carolyn Fong for The New York Times
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.
As director of N.I.M.H., Dr. Insel was a champion of basic research, confident that understanding genes and neurobiology would help unlock some of the most complex mental disorders.
He steered the agency’s $1.3 billion research budget toward the biology of disease. That drew criticism from some in the field, who argued that the funding should be split more evenly between neuroscience and clinical research into treatments, like medication and therapy, that could be used in the 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.”
In an interview last week, Dr. Frances, 79, said his warnings had been borne out.
“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 added that it was difficult, surveying the homeless camps proliferating in so many American cities, to feel proud of his 55 years of work in the field. 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 it differently. He does not express regret about his work, or level any criticism at his successor at the N.I.M.H., Dr. Joshua A. Gordon, like him an advocate of 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. Good treatments for serious diseases like schizophrenia and bipolar disorder already exist, he said, and it is not the job 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.”
Still, his comments have ruffled some feathers at the agency he led.
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 offered examples of two new treatments developed on the basis of neurobiological research: ketamine for treatment-resistant depression and brexanolone for postpartum depression. He said that the N.I.M.H. has also funded studies that led to treatments being used today, like a large-scale study that established the effectiveness of comprehensive services for people experiencing a first episode of psychosis.
As for the big breakthroughs, he said, they take decades to realize. 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.”
As for Dr. Insel, he sees himself in a different role now, not unlike Al Gore, who, after serving as a senator and vice president, reinvented himself as a truth-teller on 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.”
Ellen Barry covers mental health. She has served as The Times’s Boston bureau chief, London-based chief international correspondent and bureau chief in Moscow and New Delhi. She was part of a team that won the 2011 Pulitzer Prize for International Reporting. @EllenBarryNYT
Charles Tadros, M.D.
May 12, 2023
Saint Louis, Missouri