Post by Former NIMH Director Thomas Insel: Atonement
One of my first meetings when I arrived at NIMH 12 years ago was with board members of the National Alliance on Mental Illness (NAMI). I asked them how NIMH could be helpful. One board member’s request was especially memorable. “Declare a day of atonement,” she suggested. When I saw this same board member last month at the annual NAMI meeting, we both recalled that 2002 meeting with a touch of regret. I wished I had had a better response to her request. And, as she said to me last month, “I wished I had asked for a week.”
As it turns out, Mental Illness Awareness Week this year began with Yom Kippur, the Jewish Day of Atonement. Which begs the question: what do we (in the mental health community) need to atone for? There are so many answers. For some, it may be the culture of blame and shame perpetuated for years by clinicians who explained all mental illness as being caused by trauma and evil parents. For others, it may be the singular reliance on medication and modifying behavior rather than holistic care and the provision of skills. Others will name the paternalistic structure of mental health care, which can undermine rather than empower individuals and their families. The list goes on. Maybe it would take a week, not just a day, to capture the many complaints.
My own favorite atonement issue for Mental Illness Awareness Week this year is the lack of humility in our field. Mental disorders are among the most complex problems in medicine, with challenges at every level from neurons to neighborhoods. Yet, we know so little about mechanisms at each level. Too often, we have been guided more by religion than science. That is, so much of mental health care is based on faith and intuition, not science and evidence. On the plus side, we put a premium on listening and compassion. We help people to change through understanding. But not enough of our care has been standardized to a high level of quality, as expected in the rest of medicine.
On the research side, it’s easy to lose humility. The pace of discovery in genomics and neuroscience is ever more rapid—this week’s Nobel Prize in Physiology or Medicine is a good example of how neuroscience is revealing the fundamentals of brain activity—in this case describing the brain’s “GPS” network. Advances in systems neuroscience, from dissecting circuits to human brain imaging, are unequivocally stunning. But, and this is a humbling caveat, we simply have not been able to translate this revolution in neuroscience to diagnostics or therapeutics for people with mental disorders.
Why the disconnect? Translation takes time. Translation requires replication, regulation, and ultimately reimbursement. Fundamentally, translation is really difficult. For instance, we have thousands of neuroimaging studies but none that has delivered a clinically useful biomarker. For NIMH this is a humbling realization—we still lack biomarkers to identify who should get which treatment. We still lack effective treatments for many aspects of mental illness.
So this year on Mental Illness Awareness Week, my call is for humility. We need to be aware that mental disorders are immensely complex—too complex for scientists, clinicians, patients, or families to solve alone. Prevention, recovery, and cure—the NIMH vision—need a collective effort. Beyond the day—or week—of atonement, we need a massive campaign to transform diagnosis and treatment.