New York TimesBy JOHN C. MARKOWITZOCT. 14, 2016The 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…
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…
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]…
We need both neuroscience and clinical research. I hope the institute will re-establish that balance.
Question: Are you saying Google is a better place to do mental-health research than the NIMH?Answer: I wouldn’t quite put it that way, 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.
I think he really believes that mental illnesses are all brain disorders, a belief it would be hard for any practitioner to sustain. But then he wasn’t "any practitioner" – having never seen a patient after finishing his Residency. I always thought his notion of Psychiatry as a Clinical Neuroscience was strange since he was never in the Clinic himself. In my view, he was paradoxically a detriment to Biological Research. Rather than allow researchers to follow their own Muses, he had them boxed in following his – and his blew about in the wind from shiny object to shiny object.
Here’s my take on Insel’s RDoC. There is no risk that he will be remembered as a visionary. It’s a classic case of top-down replacing bottom-up clinical science.
Here is a link to the article.
I don’t think that there is too much neuroscience. In fact, the real problem with current clinical research is that anyone who wants to do a trial can’t beat the existing gold standards. I just heard a researcher this weekend bemoan that fact that to get funded for a psychotherapy trial for bulimia, they had to agree to run it against CBT x 21 sessions. They could not demonstrate any superiority to CBT even though it was as effective.
I was quite pleased to hear that was necessary so that we stop doing endless studies of therapies that are no more effective than what we currently do.
And every clinician knows that is not the problem. The problem is rationed resources and when it comes to therapists – none that do any research based psychotherapy.
I do think there is too much emphasis on shoe horning in neuroscience no matter what. BTW 1bom, do you deliver research based psychotherapy? Or are you part of the problem?
1bym
Say more about your question.
They’re missing the end game. Phenomenology is more important than the marker. What will happen is that they will shoehorn the descriptions to fit the marker rather than correlate markers to valid constructs. Of course you need valid constructs to begin with and that’s where DSM fails (it’s becoming more shockingly clear that many of the poobahs don’t really understand the difference between reliability and validity). A pox on all houses, basically as this top-down approach will lead to thousands of blind alleys and financially successful careers of hundreds of publications of no clinically redeeming value.
Once again, we learn that central planning doesn’t work, as if we didn’t know that already. Dr. Carroll’s early point about Soviet research is increasingly relevant to American research.
It was in large part written in relation to Dr. Dawson’s “And every clinician knows that is not the problem. The problem is… when it comes to therapists – none that do any research based psychotherapy.”
“Research based” being a stand in for “evidence based.”