We spoke to him before and after last week’s mass shooting in Oregon; his answers have been edited for clarity and length.
What was your reaction to the deadly rampage at the Oregon community college?
Insel: When there is another mass shooting, I worry about our rush to connect violence and mental illness. Most people who are violent are not mentally ill, and most people who are mentally ill are not violent.
That said, we should not deny that nearly all of these horrific crimes have been committed by someone with an untreated mental illness. The operative word there is “untreated.” The risk of violence drops precipitously with treatment. Knowing that the average duration of untreated psychosis in a recent study was 74 weeks, one way to make a difference is to ensure that we detect psychosis early and treat the first episode quickly and comprehensively.
Research tells us that most young adults were struggling for two or three years before they had a psychotic break. We should take a page from our approach to heart disease by identifying who is at highest risk and developing interventions that preempt psychosis.
Is there anything to be done for people who are mentally ill who don’t seek treatment?
Insel: One of the great challenges in this field is how to help people who do not want help. People with paranoid delusions often deny they are ill. People with severe depression may feel hopeless and helpless, refusing help. Engaging the affected person takes an artful approach to identifying issues they want help with. Of course, at some point, when a person is a threat to self or others, involuntary treatment becomes essential. We recognize the need for involuntary treatment for a 75-year-old with a brain disorder like dementia, but we are reluctant to provide the same care for a 25-year-old who is homeless and confused from a brain disorder like schizophrenia.
Why are you leaving at this time to go to Google?
Insel: I got an offer [that] seemed to me to be intriguing and, frankly, a bit disruptive. For a company like Google, that it would have interest in making an impact in the area of mental health, I thought it was pretty exciting.
While technology has had an enormous impact . . . in so many parts of our lives, it still really hasn’t had the impact one might expect in health care. And as I thought about this, and talking to people at a number of companies, not just at Google, I got the sense [that] if there was one area that was both in need of a disruptive impact as well as where the potential for having a very significant impact might be made, it was with health care, maybe mental health care, because of the particular nature of both our diagnostics and our therapeutics.
One of the possibilities here is, by using the technologies we already have, technologies that are linked to a cellphone, technologies that are linked to the Internet, we may be able to get much more information about behavior than what we’ve been able to use in making a diagnosis.
Are you veering away from direct basic science research and more toward wearable technology and other things?
Insel: I don’t think it’s an either or. But I do think we’ve already invested heavily in the technologies of genomics and imaging. And we have fantastic results to show for that. Now, oddly enough, what we haven’t done as well is to create the next generation of technologies for tracking behavior and, in particular, behavioral change. And that includes everything from sleep to speech to activity to social networks, all of these things that all of us do all the time that we don’t track, at least not in the way for health purposes, in a way that really could be transformative if we do it well.
Do you expect that pursuing new investigations will be easier at places like Google and its new parent company, Alphabet?
Insel: It is true that at Alphabet, they’re always looking for out-of-the box ideas. The language they use is often “Give us something that will have a 10x impact,” meaning it will change something tenfold rather than just an incremental impact. . . . But I wouldn’t say that I’m all that frustrated about being a public servant. I think that [the National Institutes of Health] and NIMH have done spectacular things. There’s actually right now a very rapid pace of progress in certain areas like the BRAIN Initiative. . . .
What was really the offer I couldn’t refuse was the possibility that a big tech company like Alphabet would want to do something in this area.
Five years in, what’s the reaction to RDoC [Research Domain Criteria, a new blueprint for how to study mental illness based more on genomics and brain biology] and the shift of NIMH’s priorities toward work around biological tests for mental illness?
Insel: I have not seen a lot of blowback. . . . I think most scientists understand that if we’re going to make progress in this field, we have to get far more precise diagnostic terms — and a term like depression, which is only defined by behavioral aspects of the syndrome, is not going to get us where we need to be.
We have to bring in lots of different levels of information. It’s not all biology. It also could be social determinants. It could [be] aspects of cognition. There’s just a whole series of all kinds of data that we don’t take into account now when we put a label on somebody like major depressive disorder.
What would you have liked to have done at NIMH that you were not able to do?
Insel: When I look at what I would say is my biggest failure, it’s that I don’t think that the investment we made with the money that we were given had an impact on the suicide rate, on the morbidity of any major mental illness. . . .
There are lots of explanations for why the rapid progress in science didn’t translate to much better outcomes for people with serious mental illness. I hear all that, but what keeps me up at night is knowing that the suicide rate is now higher than the mortality rate from breast cancer — I just find that extraordinary. That there are almost three times the number of suicides as homicides in this country — the homicide rate has come down by 50 percent and the suicide rate is trending up. That is, to me, unacceptable.
What could you have done differently to change that trajectory?
Insel: We need better science. Just as we need that in cancer and heart disease and diabetes, we need to do that for mental illness. So we have to keep raising the bar, investing in science, getting the very best science done. . . .
When I first came into the job in 2002, one of the very first talks I gave I talked about the excitement of the science, and at that point, I was talking mostly about epigenetics [the study of how environments affect genes], which was just becoming a reality. And it seemed to me to be transformative and so exciting. It was such an innovation. And [then] someone in the audience said, “Excuse me, but our house is on fire, and you’re talking to me about the chemistry of the paint.”
I never forgot that. And I think we have to be very honest with ourselves. That indeed the chemistry of the paint is important and very interesting and it will probably make sure it’s a better and safer house in 10 to 20 years. But we have to do something with the house that’s on fire as well. I worry that we didn’t do well enough on that score.