a recession…

Posted on Sunday 22 November 2015

“We are at an extraordinary moment when the entire scientific foundation for mental health is shifting, with the 20th century discipline of psychiatry becoming the 21st century discipline of clinical neuroscience,” Thomas Insel said before a meeting on the challenges facing mental health research at the Royal Society in London on 31 August… The seismic shift had been driven by what he described as three “revolutionary changes” in thinking, the first of which was that mental illness was increasingly being recognised as a disorder of brain circuitry, rather than as a chemical imbalance, thanks to neuroimaging techniques and the discovery of some key biomarkers.

NIMH Director Tom Insel labeled the time of this speech four years ago as "an extraordinary moment," but I recall it in a different way. The DSM Task Force had just admitted that its push for a neuroscience based DSM-5 was being abandoned [for lack of confirmation]. And it had just become crystal clear that PHARMA was making a massive exodus from CNS R&D [no discoveries, no leads]. The KOL set was at DEFCON 4 and having multiple meetings hoping to get PHARMA to recant. I guess Dr. Insel and I saw it as different kinds of extraordinary moments.

I have no idea what he was referring to with "mental illness was increasingly being recognised as a disorder of brain circuitry, rather than as a chemical imbalance, thanks to neuroimaging techniques and the discovery of some key biomarkers." I still don’t know. I assumed at the time that he was rallying the disheartened troops with hope for the future. I specifically recall the quote because it was the first time I heard the term "chemical imbalance" from a psychiatrist, and it was absolutely the first time I ever heard "a disorder of brain circuitry" from anyone – ever.

I now see that summer of 2011 as marking a change in Dr. Insel. Before that he seemed to be an inspired neuroscience cheerleader filled with a boyish exuberance.  Since that summer, he’s talked a lot about how inadequate the current drugs are; lamented the intransigence of the mental illness statistics; come up with scheme after scheme to jump-start drug development; broken away from the APA’s DSM diagnoses; declared his nebulous RDoC to be a prerequisite for NIMH Grant money. It seems like he began to talk as if we know nothing, like we’re starting over from scratch.

What brought all of this to mind was reading some of the recent war of words between Psychiatrist Ronald Pies and antipsychiatrist Philip Hickey, centering on who said what when about "chemical imbalances" [My Response To Dr. Pies]. Reading it, I remembered Insel’s quote above, and in the process of looking it, I ran across this article from Insel’s presentation at the 2014 APA meeting – From Psychiatry to Clinical Neuroscience:
PsychiatricNews Update
by Tom Insel
May 3, 2014

The diagnosis and treatment of mental illness is haunted by four “inconvenient truths.” That’s what NIMH Director Thomas Insel, M.D., told APA members today in his annual meeting lecture “From Psychiatry to Clinical Neuroscience.” Those inconvenient truths are these:
  1. We have failed to “bend the curve” in the prevalence and the cost of mental illness
  2. More people are getting more treatment, but outcomes are not getting better. So, more of today’s treatments may not be sufficient to bend the curve.
  3. We don’t know enough to ensure prevention, recovery, or cure for too many people with serious mental illness.
  4. We need to transform diagnostics and therapeutics if we are going to make significant progress.
Insel outlined some of the problems that have hindered efforts to bend the curve. These include the fact that diagnosis is limited to observable symptoms, and detection is almost invariably late; etiology of most mental illness is unknown; and prevention is not well developed for most disorders. Treatment is trial and error, and there are no cures and no vaccines.

Moreover, what is known as the mental health “system” is a poorly integrated maze of nonspecific pathways of care, with some people entering through the emergency department, criminal justice system, the primary care system, or nonprofessional services. Diagnosis and treatment vary from provider to provider and from patient to patient.
Again, that’s another indictment from someone who has been in a position of power, someone who might have had an impact on these things. But then he goes back to his usual cheerleading mode – outdoing earlier versions with the part in red [though again I’m not sure what research he’s referring to]:
Knowledge of the brain, despite enormous advances in recent years, is still in its infancy, Insel pointed out. “The brain is a world consisting of a number of unexplored continents and great stretches of unknown territory,” he said. But Insel also described a promising future in which mental illness is re-envisioned as a disorder of brain circuitry that will be greatly advanced by the president obama’s brain initiative, announced in April 2013.

Research is revealing how chemical imbalances can lead to circuit dysfunction, and in turn to behavioral symptoms, and Insel said the connections that are emerging can be used in the development of diagnostic tests for brain disorders that are today diagnosed late through observation of symptoms. “We can now study the mind with the tools of neuroscience,” he said. For instance, he presented evidence that is revealing ADHD to be a disorder of delayed cortical maturation. He also presented evidence of schizophrenia as neurodevelopmental disorder with distinct risk and prodromal stages that allow for early intervention.

Finally, he described the NIMH Research Domain Criteria [RDoC] project, which he said will work in tandem with DSM. “DSM/ICD will continue to be the basis of clinical care,” he said. “RDoC is a framework for research in which NIMH will support researchers to deconstruct current diagnostic categories or identify dimensions that extend across categories. RDoC will develop through an information commons that integrates data from many sources, transforming the way we diagnose mental disorders in the future.”
And now, a year and a half later, he’s abruptly moving on to Google, and his parting remarks  though spoken softly, also sound like an indictment – in the range of bitter:
Silicon Valley offers a fresh way to tackle conditions such as schizophrenia says US mental-health expert Thomas Insel
The New Scientist
By Sally Adee
Nov 4, 2015

… after giving heart and soul to mental-health problems over the last 13 years working in government, I have not seen any improvement for either morbidity or mortality for serious mental illness – so I’m ready to try a different approach. If it means using the tools available in the private sector, let’s go for it.

… but I don’t think complicated problems like early detection of psychosis or finding ways to get more people with depression into optimal care are ever going to be solved solely by government or the private sector, or through philanthropy. Five years ago, the NIMH launched a big project to transform diagnosis. But did we have the analytical firepower to do that? No. If anybody has it, companies like IBM, Apple or Google do – those kinds of high-powered tech engines…
For as much as I’ve criticized Dr. Insel over the years, I have to say that I have sympathy for some of his bitterness. He came to the job at the pinnacle of what I call "the KOL Age" in my mind. The drug pipeline was still flowing, nobody much had caught on to the guest-author/ghost-author/PHARMA racket. TMAP was spreading from state to state, and the APA was sure that a biological DSM was around the corner. Dr. Nemeroff, Insel’s most recent chief, was still the "boss of bosses." Senator Grassley and Paul Thacker were years in the future. Articles like Paxil Study 329 were the rule and there was no sobering Black Box Warning yet in place. Dr. Insel’s dreams of neuro-biological research and of psychiatry becoming Clinical Neuroscience made a lot more sense to a lot more people then than they do now. After all, the genome had just been cracked. There were new neurotechnologies all over the place. With all that, breakthroughs were surely just around the corner.

Were I to speculate about what went wrong, I’d list a number of things. Everything about his NIMH’s effort was based in technology and ideology rather than precise clinical medicine and high standards in scientific reporting. Insel was right when he figured out that the DSM was a big problem – no basis for research. But the problem wasn’t clinical diagnosis, it was that system itself. Instead of limiting the domain by careful case selection, almost every study went for a home run. He would’ve done well to go back to basics. He was too controlling about what the applicants did instead of setting high standards for how they did it and how it was reported. Instead of locating and developing solid scientists, he supported the usual suspects. There is likely a segment of mental illness where his Clinical Neuroscience is an appropriate model, but he drank the koolade and  saw it as everything. So instead of home runs, he ended up giving us a fist full of rain checks. But my Monday morning quarterbacking isn’t the point. The point is that Tom Insel wanted to officiate a paradigm shift, and he seems bitter and somewhat blaming about the results. That’s just not what was in his cards. Instead, he was around for a recession.

There are a couple of commentaries about him and his tenure worth looking at [Thomas Insel Leaves NIMH for Google – What can it mean?, Blazing Trails in Brain Science]. I expect there will be others. I hope down the road, he can give us a more introspective and helpful review than his comments so far…

    felonious grammar
    November 22, 2015 | 3:36 PM

    O.K., Dr. Mickey Nardo, your name isn’t Daniel. My apologies.

    Isn’t it just painfully obvious that the problems of mental instability are multi-disciplinary in nature?

    James O'Brien, M.D.
    November 22, 2015 | 9:43 PM

    South Park just had a show spoofing “sponsored content”. Meaning it’s now increasingly impossible to tell the difference between news and advertisements. I can’t tell anymore if Insel is a scientist or an ad. There’s not really actual useful science happening in uberbiopsych but the marketing of “exciting and new” never stops.

    November 23, 2015 | 9:04 AM

    “”Research is revealing how chemical imbalances can lead to circuit dysfunction, and in turn to behavioral symptoms, and Insel said the connections that are emerging can be used in the development of diagnostic tests for brain disorders that are today diagnosed late through observation of symptoms.””

    Anyone want to share this quote by Dr. Insel with Dr. Pies? Not that it would really matter based on Dr. Pies’ constant denials that psychiatry ever espoused the chemical imbalance theories in spite of overwhelming evidence that it did.

    Bernard Carroll
    November 23, 2015 | 11:02 AM

    The name of the game is to keep the game going.

    James O'Brien, M.D.
    November 24, 2015 | 12:35 AM


    What is he saying that’s really new here?

    It’s not science, it’s an ad.

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