Four inconvenient truths of mental illness treatment

Tom Insel, director of the National Institute of Mental Health, believes in the power of neuroscience when it comes to treatment of mental illness. While he noted powerful and positive statistics about the outcomes science has had on heart disease, AIDS, and stroke, he’s also quick to point out the lack of developments in the area of suicide and mental illness.

During a plenary session on Monday at the 2014 National Council for Behavioral Health conference, Insel presented “four inconvenient truths” relating to the treatment of mental illness.

1. We have failed to bend the curve for morbidity and mortality from mental illness.

It’s important to be honest about this, he said, because this stands in contrast to many other areas of medicine. There are many reasons for why this may be the case:

• Lack of access

• Stigma

• “Broken” system

• Poor care

Additionally, Insel believes that there is a lack of accountability for these outcomes. There should be someone who is responsible for fixing these issues, in terms of policies, he explained. Fragmentation can also be a large issue and the field is currently moving toward one of integration.

Insel mentioned that a major contributing factor to the failure to bend the curve is that a large number of the severely mentally ill end up in the criminal justice system instead of the healthcare system. “Imagine this for diabetes or hypertension or a form of cancer: If I told you that in 44 out of 50 states the largest institution to provide care is a prison or a jail – that there are ten times more people with these disorders in the criminal justice than in the state health system,” he said.

2. More people today are getting more of the treatments we have to offer but it doesn’t appear obvious that outcomes are any better.

Access and quantity are not the only things that need to be improved in order to bend the curve. Options and quality of care are equally as important, Insel said. “If we’re going to improve options and quality, we’ve got to become very different,” he continued. What needs to change is for behavioral disorders to be thought of as brain disorders and behavioral health to be thought of as brain health.

This will allow for new insights about the brain, which Insel said are profoundly exciting and will give the field an entirely different view of how these disorders are diagnosed and treated.

He spoke to the attendees of the conference about the current projects being worked on both among his group and the government. The BRAIN (Brain Research Through Advancing Innovative Neurotechnologies) initiative is part of a new Presidential focus aimed at revolutionizing understanding of the human brain. The Human Connectome Project is a research project with a goal of mapping the full wiring diagram of the human brain. It will answer questions such as:

• How are any two areas of the brain connected?
• How do any two individuals differ in the way those connections are made?
• How are those connections different in someone who has a psychotic illness and someone who doesn’t?
• How are those connections different in someone who’s at risk of PTSD and someone who is not?

There would be tools to interrogate the brain in the way that there are tools to interrogate the heart, Insel explained. In about a week, the Human Connectome Project will be releasing data on the first 500 volunteers that were a part of the project. All together there will be 1,200 volunteers, including 300 twin pairs. All of this data will become public on a quarterly basis.

Treatments should be able to shift from “fixing chemistry” to tuning a circuit in the brain, he said.

3. We still don’t know enough to ensure prevention, recovery or cure for many people with severe mental illness.

Insel explained that if this area of the healthcare field is committed to making profound progress, there has to be much more learned through two different channels.

• Change the way diagnosis is done
• Change the way treatment is done

He applied some thoughts from cancer treatment research in which it was determined that cancer should not be defined by the organ of origin. “To say that someone has a breast cancer is like saying that someone has a fever,” he explained. “There are so many different types of breast cancer. We need to know what they look like pathologically under a microscope and at a molecular level.”

It’s at molecular pathology, the genetic mutation, that can tell the researcher which treatment to utilize. With that understanding of precision medicine, that various levels of information can be brought into the diagnosis rather than using the observation of symptoms that is being used today.

He also believes that the “DSM world forces us into very narrow constraints” and says that while the DSM-5 and ICD-10 can still be the basis of clinical care, “the future has to be based on something better.”

In developing the next generation of treatments, quality metrics are essential. “The big payers say, ‘It’s great for you to have parity, but show us the parity of evidence,’” Insel described. “’Show us how the psychotherapy that you claim is helpful for anorexia nervosa. Where’s the evidence for that? And who’s regulating that?’”

Other points for future treatment:

• Integration with primary care

• Person-centered treatment

• Early intervention is critical

4. Without better diagnostics and therapeutics, we may not be able to bend the curve.

As a summary point, he closed with what the field needs in order to make improvements on the outcomes of individuals with mental illness. There needs to be precision medicine beyond DSM and ICD, “something that gives us much better diagnostics.” Also, network solutions that are safe and effective will be necessary. And lastly, the field should determine a way to disseminate those innovative treatments and diagnostics to those most in need.

The takeaway message for all: “The path to better service is through better science.”