New York Times - The United States government recently announced its new director of the National Institute of Mental Health, Dr. Joshua Gordon. If you think that’s just bureaucracy as usual, think again. Mental health research, under the leadership of the previous director, Dr. Thomas Insel, underwent a quiet crisis, one with worrisome implications for the treatment of mental health. I hope Dr. Gordon will resolve it.
For decades, the National Institute of Mental Health provided crucial funding for American clinical research to determine how well psychotherapies worked as treatments (on their own as well as when combined with medications). This research produced empirical evidence supporting the effectiveness of cognitive behavioral therapy, interpersonal psychotherapy and other talking treatments.
But over the past 13 years, Dr. Insel increasingly shifted the institute’s focus to neuroscience, strangling its clinical research budget. Dr. Insel wasn’t wrong to be enthusiastic about the possibilities of neuroscientific research. Compared with the psychiatric diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), which can be vague and flawed, brain-based research holds out the promise of a precise and truly scientific understanding of mental illness.
Psychiatric diagnoses depend on clusters of signs and symptoms. For major depression, for example, some criteria are low mood; wanting to die; and sleep, appetite and energy changes. These diagnoses lack the specificity of the biological markers that neuroscience seeks to identify. If we could find a genetic, neuroimaging or brain-circuit explanation for a mental illness, it might even yield a cure, rather than just the treatment of what can be recurrent, chronic conditions.
But where does that leave patients whom today’s treatments do not help? Can they wait for neuroscience developments that may take decades to appear, or prove illusory? Staking all your money on one bet, as the institute did under Dr. Insel, has consequences.
One example: A colleague has done research demonstrating that treating depressed mothers with brief interpersonal psychotherapy helps not only the mothers but also their distressed children — children who will not improve, despite treatment, if their mothers remain ill. This study needs replication; furthermore, the same principle might also apply to anxious mothers and their children, though it has never been tested.
Why not? Because this work lacks any “neurosignatures,” which have become virtually required to receive National Institute of Mental Health funding.
In 2010, the institute introduced a system of brain diagnostics known as “research domain criteria.” These criteria discard diagnoses like post-traumatic stress disorder, examining instead phenomena such as “response to an acute threat” (i.e., fear) at various scientific levels: genes, the molecules they produce, cells, brain circuits, physiology and behavior. Establishing links up and down this ladder — linking a gene to a neurohormonal molecule, and ultimately to a behavior — produces what is called “translational” research.
Translational research is exciting. It might, for example, one day uncover a gene for psychosis. But it is also fragmentary and unproven. We could wait for decades before tantalizing neural findings translated to useful human treatments.
Nonetheless, translational research has become virtually required for funding. Although the “neurosignature” targets of the research domain criteria are not demonstrably any more useful than D.S.M. diagnoses, and though they are far more distant from clinical symptoms and treatments, the institute favors them.
As a result, clinical research has slowed to a trickle, now accounting for only 10 percent of the institute’s budget. Many clinical researchers like myself worry that this kind of research will disappear. We have too often been reluctant to voice our protest, for fear of incurring the institute’s displeasure (and losing whatever opportunities we still have for funding).
Although Dr. Insel departed the institute last November, the policy he promoted has persisted. The institute’s position is that D.S.M. diagnoses are flawed, which is true. Nonetheless, D.S.M. diagnoses still offer clinically useful, recognizable treatment goals. Dr. Insel once suggested that existing treatments are good enough — and for many patients, they are. They’re much better than they were 20 years ago, yet there remains a great need for improvement, without necessarily involving neuroscience.
Many patients continue to suffer, struggle and lead unhappy lives. Some will kill themselves, despite the best available medications, psychotherapies and skilled therapists. Patients cannot afford to wait 10 years or 20 years or longer for the results neuroscience promises. Gene therapy, for example, is unlikely to eliminate suicide or to diminish it in the next decade.
We need both neuroscience and clinical research. I hope the institute will re-establish that balance.