1 Boring Old Man

In my mind, I call it the global-specter-of-the-mental-illness-epidemic-official-introductory-paragraph. It’s the opener for many articles in our clinical trial literature, Tom Insel’s blogs introducing his most recent NIMH neuroscience initiative, countless psychopharmacology reviews, and sometimes a professional organizations’ articles about insurance parity. When I read them, they remind me of a John Birch Society film I endured in college where a white map of the world was gradually turned bright crimson by the spreading red menace of communism; or the early Steve McQueen film, the Blob, where a town and its inhabitants are eaten by a growing mass of pink jello from outer space; or a Zombie film I recently watched [a little bit of] to see what they were about; or almost any post-apocalyptic sci-fi film. The example above is from a ghost-written review article whose guest authors had undisclosed financial ties to the manufacturer of the reviewed product.

• Burden of Disease – Implications for Future Research [2001]
• THE GLOBAL BURDEN OF DISEASE, 2004 UPDATE [2004]
• The Global Economic Burden of Non-communicable Diseases [2011]

Darkness Invisible: The Hidden Global Costs of Mental Illness

Foreign Affairs

By Thomas R. Insel, Pamela Y. Collins, and Steven E. Hyman

January/February 2015

Four years ago, a team of scholars from the Harvard School of Public Health and the World Economic Forum prepared a report on the current and future global economic burden of disease. Science and medicine have made tremendous progress in combating infectious diseases during the past five decades, and the group noted that noncommunicable diseases, such as heart disease and diabetes, now pose a greater risk than contagious illnesses. In 2010, the report’s authors found, noncommunicable diseases caused 63 percent of all deaths around the world, and 80 percent of those fatalities occurred in countries that the World Bank characterizes as low income or middle income. Noncommunicable diseases are partly rooted in lifestyle and diet, and their emergence as a major risk, especially in the developing world, represents the dark side of the economic advances that have also spurred increased longevity, urbanization, and population growth. The scale of the problem is only going to grow: between 2010 and 2030, the report estimated, chronic noncommunicable diseases will reduce global GDP by $46.7 trillion.

These findings reflected a growing consensus among global health experts and economists. But the report did contain one big surprise: it predicted that the largest source of those tremendous future costs would be mental disorders, which the report forecast would account for more than a third of the global economic burden of noncommunicable diseases by 2030. Taken together, the direct economic effects of mental illness [such as spending on care] and the indirect effects [such as lost productivity] already cost the global economy around $2.5 trillion a year. By 2030, the team projected, that amount will increase to around $6 trillion, in constant dollars — more than heart disease and more than cancer, diabetes, and respiratory diseases combined.

These conclusions were dramatic and disturbing. Yet the report had virtually no impact on debates about public health policy, mostly because it did not manage to dislodge persistent and harmful misperceptions about mental illness. In wealthy countries, most people continue to view mental illness as a problem facing individuals and families, rather than as a policy challenge with significant economic and political implications. Meanwhile, in low-income and middle-income countries and within international organizations, officials tend to view mental illness as a “First World problem”; according to that view, worrying about mental health is a luxury that people living in severe poverty or amid violent conflict cannot afford.

People underestimate the costs and significance of mental illness for many reasons. At the most basic level, policymakers and public health officials tend to view mental illness as fundamentally different from other medical problems. But just like other diseases, mental illnesses are disorders of a bodily organ: the brain. In this respect, they are no different from other noncommunicable diseases.

Such steps will go a long way toward reducing the damage mental disorders inflict on societies and economies all over the world. But for such measures to succeed, policymakers and experts must first pull mental illness out of the shadows and into the center of debates about global public health.

In the past, I’ve accused Dr. Insel of misunderstanding the meaning of his title, Director. The usual meaning would be Director as in person who directs the agency that funds research. He seems to me to think it means Director as in person who directs what researchers do. There are lots of checks to keep researchers from following esoteric or trivial projects. Translational research means projects that can be put into clinical use quickly. The NIH/NIMH powers are big on Translational Research and Translational Centers [a particularly paradoxical mandate given Dr. Insel’s recent comment, "Dr. Insel reflects on the recent, great advances in brain science, and his disappointment that these developments have yet to reach a great majority of those who suffer from mental illness" – see a reset button…].

• NIMH Strategic Plan for Research
• Strategic Research Priorities
• The Anatomy of NIMH Funding
• Research Domain Criteria (RDoC) Initiative
• Future Funding Recommendations [Concept Clearances]
• FY 2015 Funding Strategies for Research Grants

• Neuroscience and Basic Behavioral Science
• Translational Research
• Services and Intervention Research
• AIDS Research
• Research Training and Career Development
• Small Business Research Opportunities
• Technology Development and Coordination
• Genomics Research Coordination
• Research on Disparities and Global Mental Health

In its first almost 40 years, NIMH enjoyed the leadership of five directors who were astute politicians and administrators. They saw their job as running interference for the scientists for funding, for Congressional support, and for public image. None of the first five Directors had reputations as scientists. They let the field shape the science through a bottom-up process. Over the last almost 20 years, the two most recent Directors acted very differently, operating with a top-down style of management that frequently was abrasive…

Given the NIMH output during the twenty years under discussion, there’s little evidence that exerting this much control has been very productive – too much form without accompanying substance. And it doesn’t take much reading of the strategic directives above to see that there is a theme to what is considered strategic [we might call it Insel’s theme]. Hopefully, the next Director will have more faith in our research community. Likewise, given the freedom to follow their intuition, they will likely be more committed [and more productive]…