Technology and Mental Health Care

Transcript for Season 3, Episode 3: Technology and Mental Health Care

Dr. Tom Insel: Well, I think a lot of people invest where they think you need innovation. So, somebody once said to me, “You know, if you want to know where to innovate, look for the duct tape, look for the things that aren't working, where there's a, you know, something’s just barely held together.” And frankly our mental health care system, if it is a system, is pretty broken. And so there's lots of opportunity here to innovate.

Judith Warner:  Welcome to The World As You’ll Know It. I’m your host, Judith Warner. 

This season, we're focusing on the brain. Specifically, we're looking at some of the most recent and astonishing advancements in brain science — discoveries that have completely altered our understanding of how the brain works, what it's capable of, and how it can be changed.

And today I’m speaking with Dr. Thomas Insel, author of the wonderful new book, Healing: Our Path from Mental Illness to Mental Health.  

I first met Tom back in 2009, when he was the director of the National Institute of Mental Health. The NIMH is the world's biggest funder of mental health research. And at the time, Tom thought that he and his team were on the brink of revolutionizing the way we think about – and talk about – mental illness.

Six years later, though, he left the NIMH for Silicon Valley.

Things just weren’t happening fast enough for him in the world of government research. After four startups, he's still there. Still eager to innovate, and still wrestling with the big questions: How do we finally make real progress in the treatment of mental illness? And above all, how can technology help?

Dr. Tom Insel, welcome! 

Dr. Tom Insel: Well, Judy, first – thanks for having me here. I'm delighted to have this conversation with you.

Judith Warner: I’m so glad to be here with you. You know, Tom, it’s funny. Reading about your career in your book was like walking through a greatest hits version of American psychiatry. So in the 1970s, you did psychoanalysis. And then the ‘80s (in your first job at the NIMH), you worked on antidepressants. In the ‘90s, you retrained as a neuroscientist. And then you came back to the NIMH, now as its director, at this incredible moment, when knowledge of the brain was just exploding. People were saying the 21st Century was going to be the “Age of the Brain.” And like in all the other moments, there you were, front and center, right when big changes were happening.

Dr. Tom Insel: I rode this phenomenal wave through the 1980s and nineties, uh, which was, was just a revolution in the tools and in the concepts that we had for how to study the brain. It was amazing. It was just, you know, I, I was so privileged to be part of that era, uh, which I think in retrospect, we'll think of as a kind of golden era for neuroscience. 

Judith Warner:  What made it a golden era? I mean, what were the new tools that you were able to work with, and then what were the new concepts or ideas that grew out of that time? 

Dr. Tom Insel: Well, I think when I started, which was in the very early 1980s, we had a sense that the brain basically, you know, you had norepinephrine and serotonin and dopamine, and a few other neurotransmitters that people knew about. The whole field of neuropeptides with hundreds of new agents, and then later, all kinds of other molecules that were very important, and other kinds of cells besides neurons that were important for brain function — all of that just transformed the way we thought about the brain, even the way we thought about mental illness. When I started I think there was a sense that these were due to some chemical imbalance. And, uh, 20 years later, there was a real sense that, well, that was a little bit simplistic in that, um, what's going on here is perhaps more of a, of a connectional problem or a circuitry problem that we need to understand this, kind of the way we think about arrhythmias in the heart. 

Judith Warner: That makes me think of something you told me when we first spoke way back when. You described to me how you’d been so inspired by what had happened with childhood leukemia. That the disease had basically gone from being a death sentence in the 1970s, when I was growing up, to being almost all the time curable. And you thought, “They were able to do that with this disease that had such a high death rate. Why can’t we do that with mental illness?” 

Dr. Tom Insel: Yeah, very much like – How did we do this for childhood leukemia? How did we do this for HIV? How did we make these, these breakthroughs that led to such better outcomes, reductions in mortality, uh, which in the case of, uh, acute lymphoblastic leukemia is a 90 percent reduction in mortality. That's pretty astounding. And, and to me, the surprise was – and I can still remember the day I had this conversation with someone from the Cancer Institute – and I was asking her like, “How did that happen?” And she said, “Here's the thing: There was never a breakthrough. It wasn't a new discovery. It wasn't a particular drug. There was no magic bullet. It happened because we did our homework. We made sure that we learned from every case. That it was a kind of big data exercise. Every child who got this illness became essentially a research volunteer. And over time, we began to figure out how to take what we had already and use it better.”

And that was actually an incredibly important insight for me, because like so many of my colleagues, I kept thinking, “There's gotta be a magic bullet out there, right? If we can just do the right set of experiments, find the right target, create the right small molecule, we’re going to find the drug that will be the cure for schizophrenia or one of these other disorders.” And I don't think that's a helpful perspective. I think it's important to understand that there may not be a magic bullet, but that doesn't mean you can't get much better outcomes.

Judith Warner:  So you mentioned earlier that there was a sea-change in thinking about mental illness, with a new focus on brain circuitry, rather than brain chemistry. What led to that insight, and what did it mean?

Dr. Tom Insel: Well, we had, we had brain imaging tools we were able to use initially with MRI and then with functional MRI. We were able to look at first, brain structure, and then, brain activity. Um, you know, not at a cellular level, but at a systems level. And there were lots of surprises. There were things that, there were, you know, brain areas that we didn't tend to think about being connected anatomically that tended to be very connected functionally. So, they would activate at the same time over and over again. Who knew that those systems were even there? We began to get an understanding of the remarkable plasticity of the brain. And we could see that, you know, the, the real estate in the cortex was used in different ways by different people. I mean, think about that for a second, Judy, that, that, you know, that the, the way the brain is wired changes when you learn to play the violin, it changes when you learn a language, it changes when, um, when you get language. It's really uh kind of fascinating to see. So much so, there was a recent paper that was published maybe a couple of months ago that showed that you could look at brain scans and you could know whether someone was multilingual or not. 

Judith Warner: And you know, what you said before about “plasticity” makes me think about why people are scared about tech. Even if they’re not using that language, talking about plasticity, they have the sense that it’s changing our brains, especially kids. 

But you’re a brain scientist who’s actually gone into tech. So I want to talk to you about those other things. But first just for starters, can you talk about what it was like to make that transition?

Dr. Tom Insel: So originally I made the jump in 2015, I went to Alphabet, it wasn't called Alphabet then, it was just called Google. And at the time we were spinning out a healthcare company called Verily, uh, which was gonna be driven by tech. So that was really my, um, baptism in the world of, of technology. But let me tell you what I was thinking at the time. It was probably not so smart, but I was, I was getting frustrated by the fact that all this science that we've been talking about really wasn't making a difference for people in the world of healthcare, particularly mental health care. And that, um, you know, the numbers, the public health numbers for disability and death were, were getting worse, not better, even though we had so much progress on the scientific side.

And, and I was thinking, “Well, you know, tech companies were really transforming a lot of other areas. And maybe we could do this in the mental health space.” I thought, “Maybe we need to do a better job, not with understanding the brain, but with just understanding behavior.” Cause what we were basically left with were just subjective reports of how people felt, which is super important. I shouldn't say “just,” but in addition to subjective reports, wouldn't it be great to have some objective evidence? So if somebody said “I'm not sleeping well,” maybe it would be useful to measure their sleep and find out like, what does their sleep architecture look like? Uh, when somebody said, you know, “I'm getting isolated socially.” Well, we actually know how to measure that. That's not that hard to do! 

Judith Warner: Yeah, what’s so cool now is that we’re basically carrying around these measurement devices all day, right? Our phones. And there's a great example in your book of “Stephen” a programmer at Google, who has bipolar disorder and he wants to create an app that will track his moods. Can you tell us that story?

Dr. Tom Insel: Yes. So this was, uh, by the way, a made-up character. He was a composite of many people that I worked with and that I knew. But the idea was that this is a young man who had been, uh, brought low by bipolar illness and then recovered. But he wanted to be able to sort of create a digital smoke alarm, you know, ‘cause he would have, like all of us, good days and bad days. But when does he need to worry? And to do that, he started looking at lots of signals that were automatically collected on his phone. He could look at the email in and text in and text out to measure his social engagement, social interaction. 

And he used natural language processing to sort of identify the sentiment and the coherence and a whole bunch of things about, um, about the quality of his texting and um, and his voice and all of that, to try to understand is he becoming manic? Is he becoming depressed? And he'd begin to see these patterns. So, the idea here – some people call this “digital phenotyping,” there are lots of names for this – but it's basically using objective signals, whether they're on a phone or on a wearable, or even like your sleep monitor, to begin to get a deeper understanding, uh, or a more accurate understanding of how you think, how you feel, how you behave.

Judith Warner: So when you talk about “signals,” you basically mean pieces of information about how someone is doing, right? I mean it, it, it seems counterintuitive, that the junk, you know, I want to say, that could be collected by my phone would be valuable, more valuable, even, than what I might tell a doctor or therapist. But at the same time, it makes a lot of sense. Because we are unreliable narrators, right? And, I guess that’s true, particularly if someone is in a place where their moods are actually distorting their thoughts. 

Dr. Tom Insel: Yeah, exactly, Judy. I mean, if you think about it for a moment, people who have a mental illness; almost by definition, there is a gap between their subjective experience and other peoples’ objective observations, right? And yet, the way that we collect information about people with mental illness is simply to ask them, “How are you doing?” This happens to be the place where they have the greatest problem. And, we still need to know that. We still need to know their subjective reports, but it's really helpful to have additional objective data. And sometimes it's that gap between the subjective and objective that's the most informative. 

Judith Warner:  How difficult has it been, though, to interpret the data that you get in a way that's really predictive of what's going on with people? 

Dr. Tom Insel: I think that's a work in progress. Part of the problem is that the ground truth that you're training to is ultimately subjective. Like, you know, when you treat somebody with severe depression, um, and they start to come out of it, um, they often feel worse and not better. Because for months, they haven't been able to feel anything at all. And so, you'll pick up for them that they're improving. And the wife knows, and the kids know, and the friends know, and yet the person who's depressed feels worse than ever. And so having a way to say, “Look, here's the objective data. You know, your wife isn't making this up. You're actually sleeping better, though you don't realize it. You're actually more active, though you don't know that yet.” And to be able to show that can really help somebody at a point where they may otherwise be the last one to know that they're improving.

Judith Warner: That’s so fascinating. And you know there's been such an explosion of mental health apps since you got started with this. I feel like every single day I’m getting something new about some kind of mental health-related app on, on my Instagram feed. Why has this area become such a magnet for investment?

Dr. Tom Insel: Well, I think a lot of people invest where they think you need innovation. So somebody once said to me, “You know, if you want to know where to innovate, look for the duct tape, look for the things that aren't working, where there's a, you know, something’s just barely held together.” And frankly, our mental health care system –  if it is a system – is pretty broken. And so there's lots of opportunity here to innovate. People ask me a lot about this question around the apps and the products and, and you know, software and hardware and how it will change mental health and mental health care. My answer is that I think the most important thing for the mental healthcare system is not the products that are coming out of the tech industry. It's the culture of the tech industry. That's what the mental healthcare world needs.

Judith Warner: What do you mean?

Dr. Tom Insel: I mean three things. That, when you're in a tech company, um, and you're building something, the first thing that anybody asks is, “What does the UX tell you?” Because in, in the world of tech, the first thing you do is you bring in the users and you have them teach you: what's the pain point, what would work for them? What would they use? What would they not use? Everything is driven by users. 

The second important cultural piece for tech is that you're always capturing data about what you do. You're trying to figure out, is it working? Is it not? And you're iterating constantly. This is something that the mental healthcare system has been completely unable to do – is to learn from its performance and improve performance accordingly. And the third thing that happens when you work in a tech company is you learn principles of accountability that are woefully lacking in the mental healthcare world. So at a company like Alphabet, you have what are called “OKRs,” objectives and key results, that you have to develop every quarter. But you also develop them on a year by year basis, and if you overshoot, you do better, you get paid more. If you undershoot, you get paid less. It’s pretty extraordinary.

Judith Warner: So, I feel that whole question of measuring outcomes has been such a big issue in mental health care for such a long time. You know, it’s that whole “as-much-art-as-science” thing. So are the apps able to measure outcomes in a real way? 

Dr. Tom Insel: It's a great question. I think it's too early to know. Certainly, um, there have been many companies that have solved this fundamental access problem. You know, if you can't find a therapist, I'm not gonna name companies, but there are lots of them where you can go online and with a click of a button, you can be connected to a navigator or a coach within minutes. That's something, right? That's a lot better, especially if you're in a rural part of the country, or if you're a minority, or you don't speak English and you're looking for a therapist, um, then you may be kind of out of luck in a lot of places. But you can now, online, you can solve that problem. I don't think we have yet solved the quality problem.

Judith Warner: So you've said interesting things about the quality issue. You said something in an interview recently that, if we're at a time where there's such a shortage of therapists, that you can go online and you can find a whole bunch of therapists who are eager to be there, because they’re having trouble finding patients, then you have to wonder why they haven’t filled their practices. And you wonder about the quality of the care that they’re providing. 

Dr. Tom Insel: The quality problem is one that I think about a lot. I think the answer is empirical. I think we have to start measuring outcomes. We don't do that in the brick and mortar world, only about 19 percent of providers actually measure anything that looks like an outcome. Um, that would be completely unacceptable anywhere else in medicine. But in mental health, somehow, that's just become the standard. I think here, um, there may be ways to bake in the measurement, to do it passively and easily. There are companies that are beginning to do that now. And then you can begin to understand and to monitor the quality question and you can figure out, you know, A, is this person effective in what they're doing? And B, what do they need to become more effective? How can we help this person? How can we improve what they do so they get better results? And, um, we absolutely can do that with the tools we have today. There is a UK company that's proven out this thesis. And they only do therapy, um, remotely. But by continually measuring their outcomes and giving feedback and a dashboard to both the therapists and the patient, they've been able to improve outcomes consistently.

Judith Warner: So this is a moment of unprecedented hostility and um, suspicion, of big tech companies. And I think people are particularly worried about the effects of Instagram and TikTok, et cetera, on kids’ mental health, and maybe on everyone's mental health. So, how do you join in that conversation; speaking from your position as a scientist, and also as somebody who really believes in the potential for tech to do good? You've said that you've seen a lot of smart people who are part of the big tech companies and who are taking this really seriously and they want to do something about it. So, how do you pull all the pieces together to be able to have a good answer, for example, for somebody who says just that, you know, the tech companies are evil. It’s a disaster, we just have to throw out the phones?  

Dr. Tom Insel: Lots of people are eager to point fingers and, um, have someone to demonize. And I get that. And especially companies that are so successful. And they have been extraordinarily good at addicting young people to their products. I mean, it is phenomenal how successful they've been. Um, the question I've been asking myself and I don't have an answer yet. Um, is, “Can they become part of the solution instead of just part of the problem?” And so I've been exploring that with some colleagues from the Harvard School of Public Health and a group called The Mental Health Coalition, that's beginning to have this conversation across the major companies. I can tell you the individuals that we engage are really eager to do something helpful here. They recognize that it's not just a reputational problem, but there are real issues about what they've done in the past. Um, whether that can be turned around or not, I'm eager to find out. I think there's certainly good intentions here. But I think we'll have to get a little bit further down the path to know exactly what that looks like.

Judith Warner: Well, I could talk to you for another hour, but I think that’s a really great place for us to end. I want to thank you so much for having this conversation. It's been so great talking to you. You've really inspired me and I, I hope that people will pick up your book, Healing, because you managed to walk us through such a big landscape of science and changing ideas, changing paradigms in the book, in a way that's at the same time, very personal and very approachable and enjoyable as well. So thank you for that. And thank you again for being here.

Dr. Tom Insel: Thank you, Judy. Great to talk to you.

Judith Warner: Thank you so much for listening to my conversation with Dr. Tom Insel. Join me next week as I speak with Dr. Tor Wager and Dr. Yoni Ashar about how we can use our minds to train our brains to let go of chronic pain.

Tor Wager: I think pain is, is so pervasive because it's a sign of, of many different things that can potentially be wrong, you know? So it occurs in almost every area of medicine and you know, many, many disorders. And so, it's, you know, it's humbling. The more we find out about the neuroscience of pain, the more complex we see it is. So I, I don't think it's right to, to simplify things down to, you know, all, all chronic pain is just fear in your brain or all chronic pain is safe, but just pain. But the message is that a, a lot of it actually is.

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