Post by Former NIMH Director Thomas Insel: The Beginning of History Illusion
In a wonderful new paper in Science, Jordi Quoidbach, Dan Gilbert, and Tim Wilson describe the “end of history illusion.”1 This is not about the Mayan calendar or a Y2K syndrome. These scientists studied 19,000 people across six studies to answer a simple question: why do people so often make decisions that their future selves regret?
Their results show that people consistently report that they have changed substantially in the past decade and just as consistently predict that they will not change nearly as much in the next decade. This is true across the lifespan, perhaps explaining why, as the authors say, “Young adults pay to remove the tattoos that teenagers paid to get, middle-aged adults rush to divorce the people whom young adults rushed to marry, and older adults visit health spas to lose what middle-aged adults visited restaurants to gain.” The “end of history illusion” is this tendency to assume that we will change little in the future even though we realize we have changed substantially in the past. Or as Dan Gilbert says it, “At every age we think we’re having the last laugh, and at every age we’re wrong.”2
The beginning of a new year is a good time to consider how we address both the past and the future. Beyond the regrets from last year and the resolutions for the new one, we look forward to 2013 wondering how things will be different. And we face the classic dilemma, usually attributed to Yogi Berra, that prediction is hard, especially about the future. But one event in the near future is assured. In thinking about 2013, it’s impossible not to reflect on the 50th anniversary of President Kennedy’s historic focus on mental health. If you have not read his special message to Congress dated February 5, 1963, it’s worth taking a few minutes to read it.3
Among many fascinating insights, you will find these remarkable words:
But two health problems—because they are of such critical size and tragic impact, and because their susceptibility to public action is so much greater than the attention they have received—are deserving of a wholly new national approach and a separate message to the Congress. These twin problems are mental illness and mental retardation.
...mental illness and mental retardation are among our most critical health problems. They occur more frequently, affect more people, require more prolonged treatment, cause more suffering by the families of the afflicted, waste more of our human resources, and constitute more financial drain upon both the public treasury and the personal finances of the individual families than any other single condition.
We as a Nation have long neglected the mentally ill and the mentally retarded. This neglect must end, if our nation is to live up to its own standards of compassion and dignity and achieve the maximum use of its manpower. This tradition of neglect must be replaced by forceful and far-reaching programs carried out at all levels of government, by private individuals and by State and local agencies in every part of the Union.
With this message, President Kennedy launched the modern mental health care system, including de-institutionalization and the community mental health movement. In some ways, the changes have been profound. In 1963, there were 530,000 psychiatric patients in state hospitals, 45 percent institutionalized for over a decade. Today there are roughly 50,000 state hospital beds and the average length of stay for psychiatric hospitalization, mostly in community hospitals, is measured in days, not weeks, months, or years. The community mental health system envisioned in 1963, along with the advent of new treatments and the growth of the workforce, led to the modern recovery movement in which many people with serious mental illness function as an integral part of society. No question, the world has changed for many people with “mental illness” and “mental retardation.” Indeed, these terms are not even considered politically correct in many circles in 2013.
Yet in terms of public health measures, such as morbidity and mortality, it’s difficult to see the vast improvement. In the same period when we have seen more than 50 percent drops in mortality for most infectious diseases, cardiovascular diseases, and several forms of cancer, the rate of suicide—usually associated with mental illness—shows little change. Longevity for those with serious mental illness cared for in the public sector falls more than two decades short of the general population.4 Neuropsychiatric diseases continue to be the largest source of morbidity, just as President Kennedy noted in 1963. In fact, the trends are going in the wrong direction, with these disorders accounting for nearly 30 percent of disability from all medical causes.6
In truth, as I think about the needs of the mental health community, the “end of history illusion” seems less a problem than the “beginning of history illusion.” In too many ways, it seems that too little has changed for those with serious mental illness over the past five decades. Yet we are always confident that the next decade will be transformative. The advent of parity and health care reform could make 2013 the tipping point. But as a scientist, I am not convinced that our problems will be solved only by more insurance coverage and better services. These are undeniably important, but sometimes even the best of current care is not good enough—an inconvenient truth for someone with pancreatic cancer, ALS, or schizophrenia. That’s simply because we do not know enough. What separates us most from the successes of the rest of medicine is not policy but ignorance. Our understanding of how to detect and treat coronary artery disease has come a long way since 1963; our understanding of how to detect and treat psychotic illnesses, PTSD, autism, not so much.
The beginning of history illusion is a problem. We must confront and admit our failures—and our successes—from the past. But we cannot, we must not allow these unfulfilled promises of the past to dampen our expectations for transformative discoveries in the future, a future that will ultimately lead to biomarkers and cures. Realistically, this may not happen in 2013, but there is every reason to expect substantial progress. As Bill Gates famously notes, “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.”
1 Quoidbach J, Gilbert DT, Wilson TD. The end of history illusion. Science. 2013 Jan 4;339(6115):96-8. doi: 10.1126/science.1229294.
2 Tierney J. Why You Won’t Be the Person You Expect to Be. The New York Times, January 3, 2013.
3 John F. Kennedy: "Special Message to the Congress on Mental Illness and Mental Retardation.,"
February 5, 1963. Online by Gerhard Peters and John T. Woolley, The American Presidency Project.
4 Colton CW, Manderscheid RW.Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states.
Prev Chronic Dis [serial online] 2006 Apr.
5 World Health Organization. (WHO 2008). The Global Burden of Disease:2004 Update.