1 Boring Old Man

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.

Insel Outlines the Psychiatry of the Future Treating Disorders of Neural Circuitry

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.

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.”

Brain expert: Why I jumped ship to Google

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…

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.