Posted on Monday 14 October 2013

No, this isn’t some old leftover image. I cut it from the program for the 60th Annual Meeting of the American Academy of Child and Adolescent Psychiatry coming up in a week or so. You might recall this more familiar version from 2005:
by Thomas R. Insel, MD and Remi Quirion, Ph.D, FRSC, CQ
JAMA. 2005 294[17]:2221–2224.

One of the fundamental insights emerging from contemporary neuroscience is that mental illnesses are brain disorders. In contrast to classic neurological illnesses that involve discrete brain lesions, mental disorders need to be addressed as disorders of distributed brain systems with symptoms forged by developmental and social experiences. While genomics will be important for revealing risk, and cellular neuroscience should provide targets for novel treatments for these disorders, it is most likely that the tools of systems neuroscience will yield the biomarkers needed to revolutionize psychiatric diagnosis and treatment. This essay considers the discoveries that will be necessary over the next two decades to translate the promise of modern neuroscience into strategies for prevention and cures of mental disorders. To deliver on this spectacular new potential, clinical neuroscience must be integrated into the discipline of psychiatry, thereby transforming current psychiatric training, tools, and practices.
It seems an odd  choice for a plenary address some eight years after his first version. When he wrote the article in 2005, he was new to the NIMH, and he excitedly gave us the map I posted last week of how he thought things were going to go. The DSM-5 Task Force was operating on the same schedule of discovery. And, as we know, the science didn’t cooperate with their plans [the same old banners…]: no neoroimaging breakthroughs; no definitive genetic findings; no biomarkers; and, oh yeah, no new drugs [an empty pipeline]:
      "To deliver on this spectacular new potential, clinical neuroscience must be integrated into the discipline of psychiatry, thereby transforming current psychiatric training, tools, and practices."
      "This transition promises much better outcomes for our patients, but to realize this clinical benefit we will need much different training for our residents."
I wonder what he’s got in mind? It makes me feel old and maybe a little dumb, because I don’t even understand how he thinks this transition promises much better outcomes for our patients, or for that matter, what different training for our residents he thinks is in order. It sounds as if he’s planning to retool psychiatry to implement the not-yet-discovered – and it’s the same not-yet-discovered that was not-yet-discovered eight years ago. So I can’t help coming across as sarcastic, even though that’s not my goal. I’m genuinely curious what he was thinking.

Parenthetically, I resent the Director of the NIMH thinking that it is in his job description to point the directions for clinical psychiatry. After leaving his own residency about the same time I did, he went to the NIMH Intramural Research program where he stayed until his position was eliminated. He then went to the Yerkes Primate Center as director [1994-1999] where he wasn’t reappointed followed by a move to direct the Center for Behavioral Neuroscience in Atlanta – finally returning to the NIMH as Director in 2002. He has never practiced clinical psychiatry, in either the public or private sector. He hasn’t even been actively part of an academic department where training is going on. So I also question his weighing in on how residents should be trained for the same reasons. What does he know about clinical psychiatry? about training residents? He’s a lab guy, and an ideological lab guy at that. It feels like he’s trying to create a psychiatry that fits what he sees in the mirror.

But back to where I started. It seems really odd to be dusting off an eight year old lecture, on this topic, in this time…
    October 14, 2013 | 1:57 PM

    Thank you for pointing out that Dr. Insel actually has little clinical experience, and how odd it is for him to be advocating for what clinical psychiatry and residency training should look like. It’s something I’ve come across often, this vast gulf between what the leaders of academic psychiatry want the rest of the field to look like, and what actually happens in clinical care.

    George Dawson, MD, DFAPA
    October 14, 2013 | 3:35 PM

    Well somebody needs to come up with some reasonable ideas. I find is unacceptable that the standard psychiatric evaluation and mental status exam has not changed a bit in the past 50 years! The only innovation in clinical psychiatry has been administrative initiatives like MOC/MOL that are not evidence based and are essentially there to suppress clinicians. Insel’s idea about a year or two of neuroscience with like minded specialists might translate into psychiatrists of the future knowing more neurology and neuroscience. For the sake of the future of the specialty – I hope they have to know it.

    October 14, 2013 | 5:57 PM

    How can psychiatrists possibly sit through this stuff, especially clinicians who treat children? They must see child behavior problems all day long. Do they really think they are all due to brain disorders?

    Bradford Wade
    October 14, 2013 | 6:11 PM

    Will clinical neuroscientists be any better trained at or more focused on ruling out the many physical illnesses and conditions that affect the brain? Or do we need a new type of medical specialist to cover that gap in patient care?

    October 14, 2013 | 6:26 PM


    I absolutely don’t know the answer to that one. When I sit in my office in our little rural clinic, I sometimes keep tally. Last Tuesday I saw one person with episodic mania stable on medications and the other fourteen were “no-brainers” – meaning problems with life and personality. That’s with adults. With kids, even less. I don’t know how they do it eg sit through this stuff.

    October 14, 2013 | 7:09 PM

    It’s really very alarming when you think about it.

    Neurology has been making the argument for more then 50 years that “Mental illness” (‘Mental disorders’ – etc) do not exist and are just random symptoms of brain dysfuction that won’t correlate with any specific cause.

    With Dr. Insels approach, in order for the NIMH to treat, cure, or prevent “Mental illness” they would need to discover every single unknown disease that exists or ever will exist that affects the nervous system and produces symptoms. And that’s only if they even first acknowlege ‘Mental Illness’ doesn’t exist (as a medical problem), which they have not yet done.

    Meanwhile, right now psychiatry is basically pseudomedicine that is made up of pseudopsychology and pseudoscience. The field is vastly expanding to treat controversal ‘disorders’, and suicide and disability attributed to a diagnosis of a ‘mental disorder’ is increasing at alarming rates, now with disability affecting more then 5% of the US poplation. The NIMH and APA deny industry influence and corruption are even factors in overdiagnosis, overprescription, worse outcomes, and lack of progress.

    “I resent the Director of the NIMH thinking that it is in his job description to point the directions for clinical psychiatry.”

    Dr. Insel and the NIMH offer little comfort for a future free of fraud and criminal industry activity. The idea of neuroscience discovering the cause of a ‘mental disorder’ seems to imply fraud outright. Even if Dr. Insel stops using the term “mental illness” and exchanges it for ‘brain dysfuction’, the edifice of psychiatry would simply collapse.

    If Dr. Insel really wanted to offer a future for psychiatry, he would introduce a sweeping anti-corruption campaign. This is the wrong time talk about neuroscience, it has only produced fake treatments and nothing else.

    October 14, 2013 | 8:08 PM

    Perhaps he’s merely turning to neurology for the same reason Willy Sutton robbed banks— that’s where the money is.

    October 14, 2013 | 8:12 PM

    O.K., so it’s an urban myth, yet there’s a Sutton’s Law in medicine.'s_law

    October 14, 2013 | 9:46 PM

    I’m not sure what Dr. Insel is doing, to be honest.

    He criticised the APA’s DSM5 publically, and wrote that Mental Disorders were ‘invallid’ conditions; He then claimed to drop all NIMH funding to any research using the manual. Then he turned right around and said ADHD and PTSD are ‘brain disorders’.

    He’s not really turning to neurology, really, he’s creating a new alternate one based on psychiatry. Who knows what his motivations are.

Sorry, the comment form is closed at this time.