1 Boring Old Man

Insel’s Techno-Utopia

by Psycritic

March 16, 2014

…But just like those utopian movements, much of academic psychiatry [especially the KOL segment] is driven by an ideology: the tenets of biopsychiatry, which the 1 Boring Old Man blog has described in detail. This ideology is assumed to be correct, and because its believers think that this system will result in a huge amount of good [i.e. "NIMH envisions a world in which mental illnesses are prevented and cured"], then people who seem to oppose this ideology are at best deeply misguided, at worst causing irrevocable harm. Furthermore, anything short of this grand vision is deemed not worth pursuing. In my mind, this is the best explanation for why things like Paxil study 329, or the Markingson case, or problematic conflicts of interest, or millions of mentally ill being locked up in jails and prisons, get ignored by the leaders of academic psychiatry. They’re seen as relatively insignificant bumps in the road in the grand utopian scheme. Last year, I wrote a somewhat tongue-in-cheek post about what if the NIMH succeeds in its utopian vision. With the recent news that the NIMH will only fund treatment studies that also examine biological etiology, things are much more serious than I thought.

At first, my trouble with the Utopia analogy was my observation that they’ve been perfectly happy with a cascade of new drugs, even though they were primarily minor variations on a central theme. I guess I was thinking about Utopia as a destination, and from my perspective, most of the new drugs and the activities of the KOLs were taking us nowhere. But I think Psycritic had something more profound in mind – a true designation [NIMH envisions a world in which mental illnesses are prevented and cured], a true path [driven by an ideology: the tenets of biopsychiatry], and a banner of truth. I must already agree with the banner of truth part, because some time back, I went out of my way to fabricate this graphic from a heroic poster from the days of the Russian revolution. The whole point is that quests for utiopia never get there.

Balancing Immediate Needs with Future Innovation

NIMH: Director’s Blog

by Tom Insel

January 26, 2012

NIMH, like all Institutes at NIH, has an advisory council that meets three times each year. The National Advisory Mental Health Council (NAMHC) is a distinguished group of scientists, advocates, clinicians, and policy experts. Each of our meetings includes a closed session to review individual grants considered for funding and a session open to the public that engages this diverse group in discussions about the larger issues that guide NIMH funding.

At last week’s session, we heard a recurrent tension around one such larger issue. Some members of Council bear witness to the poor quality of care, the unmet medical need, and the diminishing investments by states on behalf of people with mental disorders. They reasonably ask, “How are we ensuring that the science that NIMH has produced is implemented where the need is greatest?” They also question on the pay-off of genetics research. After all, two decades after the gene for Huntington’s disease was identified, we still have no effective treatments, and Huntington’s disease is genetically far simpler than schizophrenia or bipolar disorder. In contrast to so many neurological diseases, we have effective treatments for schizophrenia and bipolar disorder. NIMH should be investing to ensure these are available.

The opposing argument runs something like this. There has been no major innovation in therapeutics for most mental disorders since 1960. Current treatments are not good enough for too many. Rather than investing scarce dollars for incremental improvements or increased dissemination of mediocre interventions, we need invest in the fundamental science of brain and behavior so that we can understand how to develop better treatments.

While I may have oversimplified the two sides of this debate, the divide is substantial. Some advisors want more funds in services research; other advisors want more funds in basic neuroscience. Some are thinking of the immediate needs; others are focused on the paradigm shifts that may be revealed by another decade of research. And with the NIMH budget stretched, tough choices must be made.

Finally, we have an unprecedented opportunity for progress, real progress, in understanding mental disorders. The answers are likely to be more difficult and more complex than cancer or many single gene disorders, but the tools are now becoming available. High throughput sequencing for DNA and RNA, whole genome epigenomics, high resolution imaging of the human brain, connectomics — all of these tools are giving us a first opportunity to understand mental disorders at many levels beyond the reported symptoms or the observed signs. What the EKG did for cardiology, the bacterial culture did for infectious disease, and molecular biology did for oncology, neuroscience should provide for the study of mental disorders.

Sixty years ago, the nation faced a similar short-term vs. long-term debate about polio. The needs were growing and the causes were unknown. Some wanted funds invested only in better services, including improved iron lungs. Others argued for investing in a vaccine with a long-term goal of eradication. As David Oshinsky explains in his outstanding retelling of this debate, the government went with the services approach, leaving advocates and families to raise funds for vaccine development.1 Let us hope we don’t short-change our grandchildren, sixty years from today, by failing to invest in the long-term promise of more effective diagnostics and therapeutics for mental disorders.

I’m not opposing anything particular in his listing. But in spite of his attempts to say otherwise, he’s turned the NIMH into a National Institute of Neuroscience. And he has increasingly focused and controlled the directions that research takes [a little “o”…]. So he’ll get proposals that fit the letter of his requirements [like Dr. Trivedi’s project on personalized medicine – EMBARC] that have no chance of adding anything to our understanding or our patient care [like Dr. Trivedi’s project on personalized medicine – EMBARC]. The tools he mentions above are fancier versions of the tools he mentioned in the his clinical neuroscience outing a decade ago [tools: redux…] or my new chairman talked about in the early 1980s. They’re still waiting for some creative, independent researchers to find a productive place to use them. He’s correct that something like the development of a polio vaccine is the kind of thing that might need focused research. But there’s no polio vaccine analog in his plans. We knew what caused polio by then, and what was needed to treat it. Here, we’re still dancing in the dark.