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[Draft] Summary of Insel's Latest Papers
TLDR; We need to "close the gap" between mental health needs and what we can treat. To do this we need to focus on incorporating modern brain science and new technology into mental healthcare.
TLDR; We need to close the huge growing gap between mental health needs and what we can treat. One way to do this is to incorporate modern brain science into mental health. Specifically: call mental disorders brain disorders; train clinicians in neuroscience (clinical neuroscientists); use smartphones/data for more specific/realistic diagnoses (digital phenotyping); shed old DSM categories for new categories based off specific biological mechanisms (RDoC).
Main Ideas
We need to train clinicians on neuroscience. Even though neuroscience is not fully actionable, psychiatry residents need to learn it because brain science will yield much more effective diagnoses and treatments in the future. Psychiatry will shift away from using only subjective, observable signs and classifications (eg DSM) toward more objective and biologically based diagnoses and treatments.
“Just the formulation of mental disorders as brain disorders will be an important shift in perspective. When the residents of today are the seasoned clinicians of midcentury, they may find it difficult to believe we ever divorced psychiatry from brain science. What is exciting is to realize that residents today can be the vanguard of change to create a future with a far more scientific and more effective discipline.” (Insel 2015)
“Before research on the convergence of biology and behavior can deliver on the promise of precision medicine for mental disorders, the field must address the imprecise concepts that constrain both research and practice. Labels like “behavioral health disorders” or “mental disorders” or the awkwardly euphemistic “mental health conditions,” when juxtaposed against brain science, invite continual recapitulation of the fruitless “mind-body” and “nature-nurture” debates that have impeded a deep understanding of psychopathology. The brain continually rewires itself and changes gene expression as a function of learning and life events. And the brain is organized around tightly regulated circuits that subserve perception, motivation, cognition, emotion, and social behavior. Thus, it is imperative to include measures of both brain and behavior to understand the various aspects of dysfunction associated with disorders. Shifting from the language of “mental disorders” to “brain disorders” or “neural circuit disorders” may seem premature, but recognizing the need to incorporate more than subjective reports or observable behavior in our diagnosis of these illnesses is long overdue.” (Insel, Cuthbert 2015)
We already have effective treatments based in evidence, and yet people don’t have access. “Closing the gap between what we know and what we do is the most urgent and tractable problem we face in the world of mental health care”
“Perhaps the most important role for public health is less obvious. If one of the inconvenient truths about mental health care in the United States is that we have a fragmented and chaotic system, one of the inconspicuous truths is that we have effective treatments. In this field, perhaps more than any other area of health care, we need to close the unconscionable gap between what we know and what we do. We know how to help people recover from mood and anxiety disorders as well as psychotic illnesses. We have medications, psychotherapies, and forms of rehabilitation that have efficacy comparable to that of interventions in the rest of medicine. We have the evidence base and the experience to bend the curve on morbidity and mortality. Yet we have not translated this knowledge into an effect on public health. Closing the gap between what we know and what we do is the most urgent and tractable problem we face in the world of mental health care. This is the challenge and the opportunity for public health to bend the curve for mental health. Technology can help.”
“We need to close the gap between population health needs and mental health care reach.” (Insel 2019) Many more people need help than seek it, and the current institutions with traditional clinicians and providers are not enough.
“High rates of mental illness are found in our criminal justice system, school system, homeless shelters, primary care clinics, and emergency departments. Sometimes it seems that people with mental illness are everywhere except the mental health care system. Indeed, most population-based epidemiological studies find that more than half of the population with mental illness is not receiving mental health care.4 We can improve mental health care for the fraction being seen by psychiatrists, psychologists, social workers, and other mental health providers, but this will not bend the curve on population health unless we expand our scope of care to the millions who are outside the mental health tent. We need to close the gap between population health needs and mental health care reach.” (Insel 2019)
Brain health is one of the only areas of healthcare without accessible, actionable, objective measurements of disease. Currently, clinicians mostly use a flawed DSM-5; they hardly measure at all (if they do it can only be in-session), and further practically constrained by physician time and patient motivation.
“Just as the thermometer provided a standardized, objective measurement for detecting fever, tools to quantify health and disease parameters have transformed medicine in almost every major disease area—electrocardiograms for heart disease, blood glucose for diabetes, and, recently, genetic diagnostic tests for cancer. But when it comes to brain health, and in the case of mental illness especially, progress has been uneven. Although direct brain imaging instruments exist, most (MRI, PET, MEG) are expensive, inaccessible to many, rarely useful for deciding the treatment of an individual patient, and time-intensive to administer. While they can identify brain lesions in multiple sclerosis or dementia, they are less useful in mental disorders. This lack of measurement matters because, to borrow a truism from business, “we don’t manage well what we don’t measure well.”” (Chauvin, Insel 2018)
The smartphone enables 3 innovations that can close the gap: (1) digital phenotyping (data monitoring for better treatment/diagnoses), (2) digital interventions or support (CBT online, or peer-to-peer support), and (3) better care management tools for clinicians.
“Three innovations can close the gap between population needs and mental health care reach. First, with data from sensors, speech analytics, and keyboard use, scientists are learning how to measure cognition, mood, and behavior passively from the smartphone. This field, called “digital phenotyping,” offers a sort of digital smoke alarm for mental health issues. With appropriate consent and transparency, digital phenotyping can provide ethical and effective biomarkers that predict relapse or recovery, much the way we monitor progress in diabetes or hypertension.”
“Second, smartphone applications have been developed for interventions ranging from crisis services and peer support to evidence-based psychotherapies. These online interventions have been shown to be equivalent in efficacy to face-to-face treatments. Moreover, online treatments are more convenient and, for many people, more acceptable than brick-and-mortar care.”
“Finally, smartphones can improve care management by collecting data on service use and coordinating care in real time. Together, these three functions—measurement, intervention, and care management—can generate a learning engine that improves with experience.” (Insel 2019)
Articles and TLDRs
2019
Bending the Curve for Mental Health: Technology for a Public Health Approach (Insel 2019)
TLDR; Mental health is a large public health problem and technology can close the gap between what traditional clinicians and institutions can do and the growing number of people who aren’t being served. We have evidence for what works but it is not accessible to the public: technology can take existing knowledge to create better diagnostics (digital phenotyping), make interventions more accessible, and help provide valuable data/insights to care teams.
2018
Building the Thermometer for Mental Health (Chauvin, Insel 2018)
TLDR; Digital phenotyping offers an objective measure of mental health that can be continuous (as opposed to once or less per week), precise, and capture real-world interactions. Early studies show capabilities in detecting depression, mania, PTSD, and other strong correlations with traditional cognitive and mood assessments.
Digital phenotyping: a global tool for psychiatry (Insel 2018)
TLDR; Instead of standard subjective measurements of mental health, digital phenotyping promises objectivity; and instead of delayed or at-best weekly check-ins, it promises continuous, real world measurement of how someone is feeling. Digital phenotyping uses data from smartphone sensors and interactions (eg scrolling/typing speed). It is being developed and already finding clinically relevant signals.
Digital Technologies in Psychiatry: Present and Future (Hirschtritt, Insel 2018)
TLDR; Tech has the ability to address 5 major issues: measurement, access, care delay, fragmented care, and stigma. Digital phenotyping is showing promise for objective measurement and digital interventions are showing promise for greater access; one main challenge for both is real world adherence and usage is low so far.
Other promising uses of tech include chat bots, combining tech to support clinician or lay-clinician work, and anonymous peer support.
Preparing Physician-Scientists for an Evolving Research Ecosystem (Hirschtritt, Heaton, Insel 2018)
TLDR; Growing research opportunities funded by private companies can help us develop new diagnostics and therapeutics. Many physicians gravitate away from research due to financial barriers, but private company support of research may help increase research opportunities and have it applied toward tech-enabled new therapeutics.
“Science needs physician-scientists who understand how to take foundational knowledge and apply it to develop novel therapeutics or policy decisions. Increasingly, their research, especially high-risk research in academia, may be supported by private sources, including philanthropy. Although positions in industry may be less stable and more subject to market forces than academic medical center–based research careers, physician-scientists in the private sector may explore diverse projects in multiple roles (including product development, regulatory affairs, bioassay design, marketing strategy, and policy drafting), particularly in larger organizations. The technology industry, a significant new entrant in the biomedical research ecosystem, offers biomedical researchers massive data sets with an opportunity to explore new diagnostics and therapeutics at a scale that is usually not approachable by academia.”
Join the disruptors of health science (Insel 2018)
TLDR; There are significant opportunities to improve healthcare with access to new technology and data, but we need deep partnerships between tech companies, clinicians, and researchers to act on them. Along with billions of dollars in cash, tech companies bring product and data science expertise to the traditional health care system focused on treatment and fundamental science.
“These companies have transformed the worlds of information, entertainment and commerce. But by moving into health care, they face some formidable challenges. In my view, solving them will require deep partnerships between technology companies, clinical experts, patient advocates and academic scientists.”
2017
Digital Phenotyping: Technology for a New Science of Behavior (Insel 2017)
TLDR; In a field that hardly uses tools for measurement; and where clinicians are too busy and patients are unmotivated; we need an objective, passive, ubiquitous device to capture actionable information. Digital phenotyping (prediction and diagnosis via smartphone usage) is already showing promising results, but we need additional clinical and real world research and validation.
“What the field needs is an objective, passive, ubiquitous device to capture behavioral and cognitive information continuously. Ideally, this device would transmit actionable formation to the patient and the clinician, improving the precision of diagnosis and enabling measurement-based care at scale.”
2016
TLDR; Although we’ve learned a lot from animal studies, and early human oxytocin studies are promising, we have to learn more about what oxytocin specifically targets in humans, and what doses are effective. NIMH now requires demonstrating “target engagement” in studies in order to create more informative studies and results.
2015
Integrating neuroscience into psychiatric residency training (Insel 2015)
TLDR; Even though neuroscience is not fully actionable, psychiatry residents need to learn it because brain science will yield much more effective diagnoses and treatments in the future. Psychiatry will shift away from using only subjective, observable signs and classifications (eg DSM) toward more objective and biologically based diagnoses and treatments.
“When the residents of today are the seasoned clinicians of midcentury, they may find it difficult to believe we ever divorced psychiatry from brain science.”
Brain disorders? Precisely. Precision medicine comes to psychiatry (Insel, Cuthbert 2015)
TLDR; To create more effective treatments we need to re-name “mental” disorders as “_brain_” disorders, shift away from old diagnostic categories (DSM), and research more precise diagnosis and treatment (based in biology).
2014
Mind the Gap: Neuroscience Literacy and the Next Generation of Psychiatrists (Chung, Insel 2014)
TLDR; Psychiatry training is outdated and needs to incorporate new scientific understandings of the brain. NIMH will encourage more clinician-researchers and more neuroscience literacy in new clinicians in order to facilitate development and informed use of new therapeutic approaches and technologies.
TLDR; NIMH is setting guidelines to make mental health studies more scientifically rigorous in order to make more effective treatments in a timely manner. The focus is finding more specific disease mechanisms (eg what are the brain circuits and genes behind depression?) by requiring measuring "target engagement” (eg did the experimental treatment activate the specific brain circuit?). This will build toward more informative studies and more effective treatments.
Some quotes
“Perhaps the most important role for public health is less obvious. If one of the inconvenient truths about mental health care in the United States is that we have a fragmented and chaotic system, one of the inconspicuous truths is that we have effective treatments. In this field, perhaps more than any other area of health care, we need to close the unconscionable gap between what we know and what we do. We know how to help people recover from mood and anxiety disorders as well as psychotic illnesses. We have medications, psychotherapies, and forms of rehabilitation that have efficacy comparable to that of interventions in the rest of medicine. We have the evidence base and the experience to bend the curve on morbidity and mortality. Yet we have not translated this knowledge into an effect on public health. Closing the gap between what we know and what we do is the most urgent and tractable problem we face in the world of mental health care. This is the challenge and the opportunity for public health to bend the curve for mental health. Technology can help.” (Insel 2019)
“By expanding our field of view to examine population needs rather than only those in the mental health care system, we can reduce morbidity and mortality among most of the people affected, including those in our jails, our schools, and our homeless shelters. By focusing on the diverse needs of people with serious mental illness, a public health approach can build out the framework for recovery, including psychosocial supports and the need for inclusion and equity.” (Insel 2019)
"The second issue is related to access to mental health services. In many parts of the developed world and most parts of the developing world, evidence-based mental health care is not available. The Substance Abuse and Mental Health Services Administration reports that 55% of U.S. counties lack a mental health professional (9). A recent interagency report on the state of treatment for serious mental illness reported that about 2% of patients receive evidence-based treatments such as assertive community treatment, supported employment, and family psychoeducation (10).” (Hirschtritt, Insel 2018)
“In recent years, multiple studies have addressed the efficacy—a measure of how well an intervention leads to the expected results in an ideal or controlled circumstance—of digital mental health interventions. However, fewer studies have directly measured the effectiveness—the degree to which an intervention performs under real-world conditions—of these rapidly evolving technologies. Nevertheless, available evidence suggests the value of digital interventions relative to face-to-face interventions as a means of improving access to evidence-based treatments…If the target is access, then the litmus test will be the shift from efficacy to effectiveness, which will require adoption of digital interventions at scale and sustained engagement.” (Hirschtritt, Insel 2018)
“The gap between efficacy and effectiveness is nontrivial. In fact, efforts to move digital interventions from research into practice have generally failed (33). Outside of research protocols, patients and providers either do not adopt or do not adhere to online treatments. Mohr et al. (34) remind us that, going forward, we need to consider digital interventions as technology-enabled services rather than stand-alone products, integrating them into the fabric of a patient’s life and the workflow of a provider’s practice. To improve adoption and adherence, the next generation of digital interventions will likely look less like Internet-based manualized treatment and more like the video games for ADHD or immersive VR.” (Hirschtritt, Insel 2018)
“There are few areas of medicine undergoing the profound changes we see in psychiatry today. Over the past decade, the fundamental sciences underlying psychiatry have begun to shift from psychology and pharmacology to neuroscience and cognitive science. As the tools of neuroscience have progressed, we can begin to understand the disorders of the mind by studying the brain. The two related disciplines of systems neuroscience and cognitive science hold particular promise for revealing how brain activity is converted to mental activity and behavior.” (Insel 2015)
“First, we will see major changes in diagnosis. Psychiatric diagnosis, in contrast to diagnosis in most areas of medicine, relies solely on observable signs and subjective symptoms. Our diagnostic criteria are consensus definitions of symptoms that cluster together. While this approach offers reliability and clear communication, it lacks biological validity and therefore cannot provide the necessary precision for selecting treatments. Over the next five years, data from genomics, systems neuroscience, and cognitive science should help us to transform diagnostics by augmenting subjective reports with objective measures.” (Insel 2015)
“How will we tune neural circuits? Both invasive (deep brain stimulation) and non-invasive (trans-cranial magnetic stimulation) tools have been developed for neuromodulation. It seems likely that psychotherapy that involves learning and skill building also alters regional brain function, tuning circuits through the brain’s remarkable neuroplasticity.” (Insel 2015)
“Just the formulation of mental disorders as brain disorders will be an important shift in perspective. When the residents of today are the seasoned clinicians of midcentury, they may find it difficult to believe we ever divorced psychiatry from brain science. What is exciting is to realize that residents today can be the vanguard of change to create a future with a far more scientific and more effective discipline.” (Insel 2015)
“Diagnosis in psychiatry, in contrast to most of medicine, remains restricted to subjective symptoms and observable signs. Clinicians rightly pride themselves on their empathic listening and well-honed observational skills. But recently psychiatry has undergone a tectonic shift as the intellectual foundation of the discipline begins to incorporate the concepts of modern biology, especially contemporary cognitive, affective, and social neuroscience. As these rapidly evolving sciences yield new insights into the neural basis of normal and abnormal behavior, syndromes once considered exclusively as “mental” are being reconsidered as “brain” disorders—or, to be more precise, as syndromes of disrupted neural, cognitive, and behavioral systems.” (Insel, Cuthbert 2015)
“Before research on the convergence of biology and behavior can deliver on the promise of precision medicine for mental disorders, the field must address the imprecise concepts that constrain both research and practice. Labels like “behavioral health disorders” or “mental disorders” or the awkwardly euphemistic “mental health conditions,” when juxtaposed against brain science, invite continual recapitulation of the fruitless “mind-body” and “nature-nurture” debates that have impeded a deep understanding of psychopathology. The brain continually rewires itself and changes gene expression as a function of learning and life events. And the brain is organized around tightly regulated circuits that subserve perception, motivation, cognition, emotion, and social behavior. Thus, it is imperative to include measures of both brain and behavior to understand the various aspects of dysfunction associated with disorders. Shifting from the language of “mental disorders” to “brain disorders” or “neural circuit disorders” may seem premature, but recognizing the need to incorporate more than subjective reports or observable behavior in our diagnosis of these illnesses is long overdue.” (Insel, Cuthbert 2015)
“Even more vexing is the separation of psychiatry from modern neuroscience, especially because neuroscience has transformed our understanding and approaches to that organ, the brain [1]. Despite the revolution in brain research of the past few decades, psychiatry continues to train its newest practitioners according to an outdated model of how the brain works or, in many cases, just ignores it. Fewer than half of US psychiatry residency programs provide any education in modern systems neuroscience [2, 3].” (Chung and Insel 2014)
“This trend not withstanding, psychiatry continues to face a workforce shortage. We see this shortage in two general areas. More psychiatrists are required to address the unmet treatment needs of the public [5], and we need a next generation of scientific leaders who will transform our diagnostics and therapeutics using neuroscience tools to address these needs. Given these twin goals, the National Institute of Mental Health (NIMH) is taking a two-pronged approach that includes next-generation efforts to identify and support trainees who will redefine psychiatry as “clinical neuroscience,” and neuroscience literacy efforts that encourage the integration of neuroscience into the training of psychiatry residents.”