The National Institute of Mental Health is the lead U.S. government institution that funds research on mental illness and, according to Thomas Insel, NIMH director from 2002-2015, “NIMH is the world’s largest funder of research on mental illness.” Given Insel’s longtime influential position, his new book, Healing: Our Path from Mental Illness to Mental Health (2022), has received a great deal of attention from psychiatry insiders and critics.
Insel begins by comforting his fellow psychiatrists with his claim that current psychiatric treatments “are as effective as some of the most widely used medications in medicine,” but he then asks this unsettling question: “If treatments are so effective, why are outcomes so dire?”
Psychiatry defenders and critics alike took notice when Insel candidly acknowledged in 2011: “Whatever we’ve been doing for five decades, it ain’t working. And when I look at the numbers—the number of suicides, number of disabilities, mortality data—it’s abysmal, and it’s not getting any better.” Reported by Gary Greenberg (The Book of Woe, 2013), Insel concluded this 2011 appraisal of psychiatry’s performance with this: “All of the ways in which we’ve approached these illnesses, and with a lot of people working very hard, the outcomes we’ve got to point to are pretty bleak.”
Insel’s acknowledgement of psychiatry’s “abysmal” treatment outcomes made it politically safe for the mainstream media to begin reporting on this phenomenon. In 2021, New York Times reporter Benedict Carey, after covering psychiatry for twenty years, concluded that psychiatry had done “little to improve the lives of the millions of people living with persistent mental distress. Almost every measure of our collective mental health—rates of suicide, anxiety, depression, addiction deaths, psychiatric prescription use—went the wrong direction, even as access to services expanded greatly.”
This claim, Carey assured Times readers, is no radical one, as he quoted Insel’s new book prior to its publication (when it was titled Recovery: Healing the Crisis of Care in American Mental Health) in which Insel asserts: “While we studied the risk factors for suicide, the death rate had climbed 33 percent. While we identified the neuroanatomy of addiction, overdose deaths had increased threefold. While we mapped the genes for schizophrenia, people with this disease were still chronically unemployed and dying 20 years early.” While the U.S suicide rate climbed by over 33 percent from 1999 to 2018, by comparison, Insel reports that “globally the suicide rate has dropped 38 percent since the mid-1990s.”
All of this despite increased treatment, as Insel reports, “Since 2001, prescriptions for psychiatric medications have more than doubled, with one in six American adults on a psychiatric drug.” However, he then poses questions that will make many readers’ heads spin: “Why, with more people getting more treatment, are the outcomes worse for people with mental illness . . . We have treatments that work. . . .Why with more people getting treated and better treatments available are we in the middle of a mental health crisis, with rising death and disability?”
For bringing this question of worsening outcomes despite increased treatment into mainstream discourse, Insel should be given credit; but unfortunately, his answers lack both logic and empirical evidence. While any NIMH director must be both a politician and a scientist, sadly, Insel comes off in his new book far more the politician than the scientist. His celebration of psychiatry as a medical discipline—despite the fact that almost every outcome measure, as New York Times reporter Carey put it, “went the wrong direction”—ensures that Insel will not upset the psychiatry establishment, but he will leave critical thinkers scratching their heads.
Insel lays out this curious equation: more effective psychiatric treatments + increased number of people in treatment = worsening outcomes. How does he explain that?
“First,” Insel tells us, “most people who would and should benefit from treatment are not receiving care,” which he attributes to “negative attitudes toward treatment, lack of access, and the nature of mental illness, which too often preclude seeking help.” While this might be an argument for poor outcomes, it is no argument for worsening outcomes. Insel offers no evidence that at present, compared to the past, there are fewer people receiving care who would benefit from treatment. Nobody, including Insel, argues that attitudes to treatment today are more negative than previous attitudes; or that there is less access to treatment today than previously so; or that in the past, the nature of mental illness less precluded people from seeking help. So, if all these variables have not worsened, how then could have outcomes worsened?
His other reasons for worsening outcomes are also only explanations for why outcomes are poor—not for why they have worsened. He tells us that “although individual treatments work, they are rarely combined to provide the kind of comprehensive care that most people need. . . . [and] there is a knowledge gap in matching treatments to individuals.” Again, nobody, including Insel, argues that these variables have worsened, and so why have outcomes worsened?
A more logical explanation for why outcomes have worsened despite increased treatment is that the treatment itself—which has increasingly consisted of medication—has not been all that effective for many individuals, and is counterproductive for many others. And so with more such treatment, there is going to be, overall, worse outcomes. For this explanation, there is a great deal of empirical evidence that Insel ignores.
In 2017, psychologist Jeffrey Vittengl published “Poorer Long-Term Outcomes among Persons with Major Depressive Disorder Treated with Medication.” Controlling for depression severity, Vittengl examined outcomes of 3,294 subjects over a nine-year period, and reported that while antidepressants may have an immediate, short-term benefit for some individuals, patients who took antidepressants had significantly more severe symptoms at the nine-year follow-up than those who did not take medication, and patients who received no medication did better than those who used medication.
Couple those findings with a 2006 NIMH funded study “The Naturalistic Course of Major Depression in the Absence of Somatic Therapy” that reported that 85 percent of non-medicated patients recovered within a year, and the authors concluded: “If as many as 85% of depressed individuals who go without somatic treatments spontaneously recover within one year, it would be extremely difficult for any intervention to demonstrate a superior result to this.”
Given the reality of this once well-known phenomenon of spontaneous recovery without medication or other somatic treatment, along with the reality of nonproductive and counterproductive effects of medication for many people, increased treatment could worsen outcomes. However, even speculation on such a possibility has no place in Insel’s book, as that would be taboo within the psychiatric establishment.
Perhaps the most glaring omission in Insel’s new book is the absence of his previous assertion as NIMH director about the treatment of individuals whom psychiatrists label with “serious mental illness” or “SMI,” a population that includes people diagnosed with “schizophrenia.” Absent from Insel’s new book is any reference to his 2013 NIMH commentary “Antipsychotics: Taking the Long View” (that has recently been removed from the NIMH website but remains republished on other sites). In that commentary, Insel surprised establishment psychiatry by agreeing, at least in large measure, with journalist Robert Whitaker that standard psychiatric medication treatments for some individuals diagnosed with SMI are counterproductive.
Whitaker, author of Anatomy of an Epidemic (2010), had brought attention to studies showing that antipsychotic drug treatment may well be the source of chronic difficulties for many individuals in the group diagnosed with SMI. Citing one study detailed in Whitaker’s book and another one that Whitaker brought to public attention following his book’s publication, Insel acknowledged in 2013: “It appears that what we currently call ‘schizophrenia’ [which Insel puts within quotation marks] may comprise disorders with quite different trajectories. For some people, remaining on medication long-term might impede a full return to wellness. For others, discontinuing medication can be disastrous.”
In an NIMH-funded study detailed by Whitaker in Anatomy of an Epidemic and noted by Insel in his 2013 NIMH commentary, lead researcher Martin Harrow followed the long-term outcomes of patients diagnosed with schizophrenia. He reported in 2007 that at the end of fifteen years, among those patients who had stopped taking antipsychotic drugs, 40 percent were judged to be in recovery; this compared to only 5 percent in recovery among those who had remained on antipsychotic drugs. Harrow continued to follow up these individuals, and at twenty years, he reported:
“While antipsychotics reduce or eliminate flagrant psychosis for most patients with schizophrenia at acute hospitalizations, four years later and continually until the twenty-year follow-ups, patients with schizophrenia not prescribed antipsychotics had significantly better work functioning . . . . The longitudinal data raise questions about prolonged treatment of schizophrenia with antipsychotic medications.”
In the second study noted by Insel in his 2013 NIMH commentary, the “gold standard” of randomized controlled trial (RCT) was applied to this issue by researcher Lex Wunderink, who reported his finding in 2013. Patients who had been assessed to have recovered from their first psychotic episode were randomly assigned either to standard medication treatment or to a program in which they were tapered off the drugs. At the end of seven years, the recovery rate for those who had been tapered off the antipsychotic drugs was 40 percent versus 18 percent recovery for those who remained on them.
A great deal of Insel’s new book is devoted to society’s failing this so-called SMI population, and so his omission of his 2013 acknowledgment is troubling. While the names Harrow and Wunderink are absent from his index, Insel does have one mention of Whitaker. Insel mocks Whitaker, calling him a conspiracy theorist for Whitaker’s pointing out—no different than the New York Times had done—financial conflicts of interest that psychiatrists have with drug companies, and how these influence prescribing practices. And Insel omits the fact that in 2013, he agreed with Whitaker’s major claim, with Insel having stated, “For some people, remaining on medication long-term might impede a full return to wellness.”
Insel’s Shocking Passions
There are other troubling aspects to Insel’s new book, especially his assertion on page 147 about what is commonly referred to as electroshock treatment: “Consider electroconvulsive therapy, or ECT. This treatment is effective in 80 percent of people with severe depression, including 50 percent of those for whom all other treatments have failed.” However, there is no reference for this claim. While Insel has five reference notes for page 147 (including two for books by celebrity ECT patients Carrie Fisher and Kitty Dukakis), he provides no reference to any studies that would back up this ECT effectiveness claim—a claim that will certainly influence some desperate people to seek ECT.
Insel is upset that ECT is available in “only 6 percent of facilities” and that a survey found “only 0.25 percent of people with depression treated with ECT.” He tells us that the stigma of ECT has occurred because, “Antipsychiatry groups have demonized it.” What do studies tell us about ECT effectiveness?
A 2019 review of the research on ECT effectiveness for depression reported that there have been no randomized placebo-controlled studies (ECT versus simulated/sham ECT) since 1985. The reviewers assessed those studies that were done prior to 1985 (five meta-analyses based on 11 studies) are of such poor quality that conclusions about efficacy are not possible. The authors concluded that given ECT’s adverse effect of permanent memory loss (and its smaller risk of mortality) that the “longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well designed, randomized, placebo-controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.”
Where did Insel come up with this 80 percent effectiveness rate for ECT? We don’t know. In the past, ECT proponents have cited a 2004 Consortium for Research in ECT (CORE) report, authored by some of the most well-known psychiatrist advocates of ECT in the world, including ECT’s most prominent promoter, psychiatrist Max Fink. This study claims: “Sustained response occurred in 79% of the sample, and remission occurred in 75% of the sample.” However, there are so many methodological problems with this study that no real scientist would take it seriously. Besides no randomized control (so one can compare the experimental group to a control group to tease out the effect of expectations), the researchers acknowledge the following: “Limitations of the present study include unblinded ratings.” In other words, ECT proponents who wanted to provide evidence of ECT’s effectiveness conducted a study in which patients known to them to have been administered ECT were being rated for ECT effectiveness. Furthermore, there is no indication whether, following treatment, as to how long those patients rated to be in remission remained so.
Insel is passionate about biological-chemical-electrical treatments and optimistic about technological breakthroughs. In addition to advocating for more ECT, he is also enthusiastic about transcranial magnetic stimulation and genomics (“I have no regrets about NIMH funding for genomics and neuroscience”).
While Insel acknowledges that research compelled psychiatry to discard its “chemical imbalance theory” of mental illness, he is now excited by psychiatry’s “circuitry defect” theory of mental illness (“The idea of mental illness as a ‘chemical imbalance’ has now given way to mental illnesses as ‘connectional’ or brain circuit disorders”); and he is enthusiastic about how cyber-technologies such as “digital phenotyping” could help predict suicidality.
Psychiatry has always claimed it is a biological-psychological-social discipline—the so-called “biopsychosocial model.” So, unsurprisingly, Insel is an advocate of psychotherapy, along with devoting a significant part of his book to social solutions, including a greater emphasis on providing supportive housing, social connections, and community for those diagnosed with SMI. On the face of it, this biopsychosocial model is uncontroversial, but how it has played out in practice is another matter, as noted by psychologist John Read and psychiatrist Joanna Moncrieff in the journal Psychological Medicine in February 2022 in their article “Depression: Why Drugs and Electricity are Not the Answer.”
Read and Moncrieff explain, “Although most clinicians subscribe to a biopsychosocial model of mental disorder” that subscribing to “the idea that treatments work by rectifying underlying biological dysfunctions relegates the role of social and psychological factors to secondary or indirect considerations . . . . equating psychiatric conditions and treatments with medical ones implies the pre-eminence of biological factors.” So while among most mental health professionals, the idea of the biopsychosocial model is uncontroversial, in practice, psychiatry’s medical model has resulted in lip service to the psychosocial—and money for the biological-chemical-electrical.
Do We Need Insel’s “Path” or a Paradigm Shift?
Insel should be given credit for acknowledging: (1) psychiatry’s worsening treatment outcomes; (2) psychiatry’s jettisoning of its chemical imbalance theory of mental illness; and (3) the scientific invalidity of the American Psychiatric Association’s diagnostic manual, the DSM (“The DSM had created a common language, but much of that language has not been validated by science”). However, he can’t allow for the possibility that the institution of psychiatry, in its quest for parity with the rest of medicine, continues to apply a medical model that has not worked.
What would have made for a more interesting book would have been at least a consideration of the possibility that psychiatry’s medical model—in which its patients are viewed as bio-chemically-electrically defective in need of bio-chemical-electrical treatments—is a failed paradigm no matter how much one acknowledges the importance of psychosocial variables.
In The Structure of Scientific Revolutions (1962), philosopher of science Thomas Kuhn concluded that most scientists accept the current paradigm, and they attempt to solve problems within that paradigm; however, when a current model cannot account for a large accumulation of observations, a handful of scientists don’t simply look for different solutions within that model but revolt against the entire paradigm. Insel is not a revolutionary but rather a longtime politician who does not need Kuhn to tell him that while most of his colleagues will be receptive to treatment tweaks and psychosocial acknowledgments, it is axiomatic that most of them will oppose a paradigm shift that might threaten their status.
For the few of us who take Kuhn seriously, psychiatry’s worsening treatment outcomes despite increased psychiatric treatment should provoke at least the consideration that a revolutionary paradigm shift is necessary.