a new kid on the block…

Posted on Thursday 28 July 2016

National Institute of Health
July 28, 2016

National Institutes of Health Director Francis S. Collins, M.D., Ph.D., announced today the selection of Joshua A. Gordon, M.D., Ph.D., as director of the National Institute of Mental Health [NIMH]. Dr. Gordon is expected to join NIH in September. ”Josh is a visionary psychiatrist and neuroscientist with deep experience in mental health research and practice.  He is exceptionally well qualified to lead the NIMH research agenda to improve mental health and treatments for mental illnesses,” said Dr. Collins. “We’re thrilled to have him join the NIH leadership team”…

Dr. Gordon will join NIH from New York City, where he serves as associate professor of Psychiatry at Columbia University Medical Center and research psychiatrist at the New York State Psychiatric Institute. In addition to his research, Dr. Gordon is an associate director of the Columbia University/New York State Psychiatric Institute Adult Psychiatry Residency Program, where he directs the neuroscience curriculum and administers the research programs for residents.

Joining the Columbia faculty in 2004, Dr. Gordon’s research has focused on the analysis of neural activity in mice carrying mutations of relevance to psychiatric disease. The lab studies genetic models of these diseases from an integrative neuroscience perspective and across multiple levels of analysis, focused on understanding how a given disease mutation leads to a particular behavior. To this end, the lab employs a range of neuroscience techniques including neurophysiology, which is the study of activity patterns in the brain, and optogenetics, which is the use of light to control neural activity. His work has direct relevance to schizophrenia, anxiety disorders and depression, and has been funded by grants from NIMH and other research organizations.  Dr. Gordon maintains a general psychiatric practice, caring for patients who suffer from the illnesses he studies in his lab.

Dr. Gordon pursued a combined M.D./Ph.D. degree at the University of California, San Francisco. Medical school coursework in psychiatry and neuroscience convinced him that the greatest need, and greatest promise, for biomedical science was in these areas. During his Ph.D. thesis, Dr. Gordon pioneered the methods necessary to study brain plasticity in the mouse visual system. Upon completion of the dual degree program at UCSF, Dr. Gordon went to Columbia University for his psychiatry residency and research fellowship…
I’m about to leave for a vacation, so this week has been filled with that getting-things-done activity that I’d rather have than catching-up-on-things when I come back. Part of that was working extra in the clinic to maintain some continuity of care. Tuesday, I saw a young man [20 y/o] that I’ve seen a few times. He is on first meeting a classic case of what has been called Asperger’s – the upper end of the Autism Spectrum. Tuesday, his mother was with him, and though she didn’t say much, there was a pleading look in her eyes. We have no services for him where I live in the mountains, and I had written the Autism Center at Emory in Atlanta in hopes that I could refer him. I  had gotten a very helpful response with offers of a variety of just-what-he-needed services – a medication clinic, socialization training, vocational rehabilitation, etc. Everything I had hoped for. On a hunch, instead of talking to the two of them, I scheduled a further meeting with his mother today. She obviously wasn’t saying what she needed to say when he was in the room.

It was a pretty good hunch. This young man had been well cared for by his family who had been devoted to him. He was teased in school, and quit in the ninth grade. He lives at home, and has been unable to find any place where he fits in. They’ve taken him to therapists and doctors throughout his life, but had never been given a diagnosis – in spite of his having been hospitalized after an angry outburst at a kid that was tormenting him. He had been started on courses of most psychiatric drugs along the way but none ever helped. So I spent about an hour today explaining the diagnosis  and the possibilities up ahead to his mother. Her relief was palpable. It was as if twenty years of her tension began to melt. She had harbored the fear that he had "schizophrenia" [a  condition she had a very distorted understanding of]. She left with a page of phone numbers to call for appointments, and I predict good things.

Driving home, I was thinking about Dr. Insel who was involved with that same Autism Center when he was at Emory before going to the NIMH. And I was thinking about why I have been such his critic. In person, I had liked him, personable, committed, obviously bright. He was not, nor had he ever been, a clinician. I don’t remember what he said at the reception at that Autism Center so long ago where I met him that made me think it, but I left thinking that his zeal for scientific discovery wasn’t tempered by a focus on clinical reality. I remembered that encounter some years later when I felt the same thing as I developed an interest in his NIMH activities – something I called his future-think – an almost desperate race to hit a home run instead of aiming to get on base.

So it was ironic to walk in and read an email that his replacement had been named. I know nothing of Dr. Gordon. I’m encouraged that he has a practice and works with residents. I hope he’s a clinician who can bring some needed balance to the NIMH. In my view, Medicine is a clinical science that has no intrinsic meaning outside of its focus on the patients we see. In my book, the kinds of services I hope my patient can get at the Autism Center are on a par with the lab guys who are looking to find out how neural networks might have something to do with the Autism he and his family struggle with. We need both and that’s not what we have had at the NIMH for a very long time.

I hope Dr. Gordon brings a new vision to the NIMH. And I hope that his first act in September is to disentangle the grant award process from all of the pet projects so important to his predecessor [things like Translational this-and-that; the RDoC; etc.] and give our scientists the latitude to compete for funding based on their own creative ideas rather than fitting into boxes preferred by the Director.
    Brett Deacon
    July 29, 2016 | 5:54 PM

    It appears Gordon shares Insel’s ideology. I watched this interview: https://www.imhro.org/brain-waves/brain-circuit-research-better-psychiatry-dr-joshua-gordon. Here are a few quotes from Gordon:

    “Our research is aimed at understanding the link between the genes which cause psychiatric disorders and the symptoms they cause by attacking the specific neural circuits that the genes alter and that are responsible for behavior.”

    “The influence my research has over my clinical practice is it gives me a different language to speak with patients. So for example with my anxiety disorder patients, which I have several, I can talk to them about how their amygdala and prefrontal cortex aren’t working in the way that would be ideal and that when we try to help them through varying cognitive-behavioral therapeutic techniques, when we try to help reduce their anxiety, what we’re trying to do is give them control, give their prefrontal cortex control over their amygdala. And not every patient appreciates that kind of discussion but the ones that do I’m able to really help them conceptualize what’s going on in their brains and I think it helps them deal with the disorder.”

    “I’m definitely more hopeful, I’m hopeful because the science is really in an unparalleled position to be able to (make) some significant breakthroughs in what I would consider the tear term, in the next 5 or 10 years. I think, we’re learning so much about how the brain works that it puts us in a wonderful position.”

    “Well, I would go back to that science, and I would…from interacting with patients every week in my practice I know that for a lot of them it’s very hard to have that kind of hope. But I try to instill in them the idea that there’s always hope around the corner. And like I said, the science, the neuroscience of psychiatric illness is really accelerating dramatically. I think we’re not there yet, but in the world of cancer, when you’re diagnosed with cancer these days, they give you survival statistics that were based on people getting diagnosed 5 years ago and they’re already wrong. There’s such a fast pace of advancement in cancer treatment that for many types of cancers people are living much longer today than they were 2 or 3 or 4 years ago with the same diagnosis. And so I think we’re not at the point where the pace of psychiatric treatment is that fast but I think with the knowledge explosion we have we will be there soon, we will soon be helping people in 3 or 4 years in ways that we could not have imagined 3 or 4 years ago and I think that’s a very hopeful thought.”

    July 29, 2016 | 8:48 PM

    “because the science is really in an unparalleled position to be able to (make) some significant breakthroughs in what I would consider the tear term, in the next 5 or 10 years.”
    Insel’s ground hog decades of translational breakthroughs. Sounds like we are not waking up from this dream anytime soon.

    Melissa Raven
    July 30, 2016 | 7:03 AM

    Joyner et al. (2016) What Happens When Underperforming Big Ideas in Research Become Entrenched? http://jama.jamanetwork.com/article.aspx?articleid=2541515
    ‘When claims about high-profile, dominant “big ideas” are viewed against their mediocre benefits, it seems that 2 basic courses of action are available. The first is to continue with calls for more funding, more complex measurements, and more sophisticated instrumentation. The second is to reevaluate and reset the current focus.’
    NIMH would, of course, argue that it it has reevaluated and reset, but it has merely shifted a few degrees, rather than the 100+-degree shift it needs, from reductionist neuro research to genuinely include life events and social factors.

    James OBrien, M.D.
    July 30, 2016 | 2:10 PM

    Thank you Melissa Raven for that link. Best JAMA article in a long time. I particularly like the point they made about sickle cell anemia, which is the point Dr. Carroll made about Huntingdon’s. And those are one error diseases, any treatment for complex multiple SNP diseases are going to be elusive. It goes without saying that EHR is a widely acknowledged disaster but that we are going to stay the course, for some reason. I shouldn’t be coy, the real reason is widely known…that it keeps the donor class oligarchs happy.

    July 30, 2016 | 6:47 PM

    oh no.

    When a psych told my parents I had “Asperger’s” I’m sure they felt relieved as well, but from my perspective, it meant my very identity had been co-opted by medical authority. It was profoundly alienating and harmful. Let’s hope your patient is one of the ones who finds his new label helpful rather than stigmatizing.

    Brett Deacon
    July 30, 2016 | 7:41 PM

    Melissa, thank you indeed for that link. The NIMH’s RDoC initiative seems like a clear example of “calls for more funding, more complex measurements, and more sophisticated instrumentation” as opposed to an effort to reevaluate and reset the current focus. My favorite quote from the NIMH article is this call for accountability:

    “When NIH funds translational or preclinical research with specific deliverables promised (as in the case of personalized medicine, and stem cell therapy), independent assessors should regularly appraise whether these deliverables were achieved and, if so, at what cost, and with what effect. Assessors must be objective, independent of the funding source, and have no professional stake in whether a particular line of research is deemphasized. The deliverable criterion should include public health benefit achieved by these initiatives (ie, measurable reductions in mortality and morbidity). Criteria such as number of publications, citations, prizes, and recognition are irrelevant as these are simply self-rewarding artifacts of the system. After several decades of substantial investment, the fundamental question is whether these big ideas have improved quality of life and life expectancy, by how much, for how many, and for whom. These are public dollars that should benefit the many, not the few.”

    Susan Molchan
    July 30, 2016 | 10:30 PM

    The website at Columbia describing Dr. Gordon’s work begins with the words “Cloning of genes” and proceeds promptly into mouse models. http://profiles.columbiapsychiatry.org/profile/jagordon In the publication list that follows I see no mention of anything to do with humans or health or care. Melissa Raven notes the most recent piece by Dr. Ioannidis and co-authors of relevance to this state of affairs. I thought of another, where he discussed how results of animal studies in neurological disease are overinflated http://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.1001609. I suspect the same would go for psychiatric disease, and that’s not even stepping a bit further back wondering if the models have any relevance at all, for where we are in the scheme of things. Many people say the incidence of serious mental illness is rising, that more people are on disability for it than ever before.
    NIMH seems out of the loop in trying to address this.

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