"Psychiatry’s Guide is out of Touch with Science", so What’s Next?

Tuesday’s (May 7, 2013) New York Times published an article with the headline: “Psychiatry’s Guide is out of Touch with Science, Experts say.” Written by science reporters, Pam Belluck and Benedict Carey, the story describes an important new initiative by the National Institute of Mental Health (NIMH), the largest source of federal funding for mental health research.

DSM-5-2 This initiative will replace the soon to be published fifth edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM-5), with a new framework for guiding research and focusing funding priorities in mental health research. Belluck and Carey’s article emphasizes the optimism and excitement shared by a number of prominent experts about the adoption of this new framework, known as the Research Domain Criteria (RDoC). In order to understand the true significance of this development, it is important for us to have a greater appreciation of the broader context in which this important change is taking place.

Towards the end of May, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This long awaited update of the DSM (colloquially referred to by some as the “Bible of Psychiatry”) has been the focus of considerable prepublication controversy among mental health professionals, has been discussed extensively in important media outlets including The York Times. Previous editions of the DSM have also received somedegree of media attention. But DSM-5 has raised the intensity of the controversy to unprecedented heights, in part because of the widely publicized criticisms of psychiatry insiders including Allan Frances (the chairof the task force that developed DSM-4) and Robert Spitzer (who chaired the DSM-3 taskforce). Criticisms of DSM-5 are similar in nature (if not intensity) to those which were leveled at both DSM-4 and DSM-3. For example, claims for the degree of reliability of diagnostic categories areexaggerated, evidence regarding the validity of the diagnostic categories is limited, and experiences that are inevitable aspects of the human condition (e.g., sadness, mourning, anxiety) are increasingly viewed as symptoms of mental illness to be treated with medication. An important aspect of the criticism is directed at the rapidly accelerating tendency to overprescribe medications for emotional distress with dubious effectiveness and potentially serious side effects. A more fundamental criticism of DSM-5 (also leveled at the previous two editions of the DSM) is directed at the disease model of psychiatry, which views emotional problems as similar in nature to physical illnesses such as tuberculosis, heart disease or cancer.Critics are also concerned about the potential for stigmatization of everyday problems in living.

Motivated by factors including the intensity of the controversy about DSM-5, the accumulating evidence that the new generation of psychiatric medications are not delivering on their initial promise, and in all probability the Obama administration’s declared intention of investing 100 million dollars in the field of brain science research, NIMH has held a series of workshops over the past 18 months, to develop the RDoc framework described in Belluck & Carey’s article. This shift in NIMH funding policy has taken place sorecently that there has not yet been an opportunity for extensive conversation within professional circles (let alone the popular media) regarding its pros and cons. A few informal exchanges I have read on professional listservs have an approving tone to them. There have, for example, been expressions of glee about what can be interpreted as a development heralding the demise of the entire DSM system, with all of its associated flaws and potentially pernicious side effects.

From my perspective, however, as a psychotherapy researcher and someone who has served on NIMH grant proposal review committees over the years, this policy change is nothing to celebrate. Although I have long been a critic of the DSM system, this NIMH policy change and the framework for the new RDoc system, make it very clear that the fundamental premise guiding future NIMH funding priorities is that the bedrock level of analysis is genetic, biological and brain science research. As Thomas Insel, Director of NIMH said in an interview conducted on Monday, May 6: “The goal of RDoc is to “reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms” (cited in Belluck & Carey’s NY Times article, May 7, 2013). This is a perpetuation and expansion of a trend that has been taking place at NIMH for many years now, that privileges the biological over all other levels of analysis (e.g., psychological, emotional, social). An important consequence of this trend has been that the proportion of NIMH funding allocated to psychotherapy research and other psychosocial interventions (e.g., modifying the nature of health delivery systems) relative to the brain sciences has been consistently diminishing over time.

The new paradigm for research that NIMH is adopting, means that the amount of funding available for the development and refinement of treatments such as psychotherapy that are not targeted directly at the brain circuitry (although they do influence it indirectly), is likely to continue to shrink, I want to be perfectly clear that I do not question the potential value of brain science research. What I do question, however, is the single minded emphasis on brain science research to the virtual exclusion of all other forms of mental health research. It is important to recognize that funding priorities shape the programs of research pursued by scientists, and thus the type of research findings that are published in professional journals and disseminated to the public. This in turn shapes the curriculum in psychiatry and clinical psychology training programs, which shapes the way in which mental health professionals understand and treat psychological and psychiatric problems. It also shapes Mental Health care funding policy. In concrete terms this explicit NIMH policy shift is likely to mean that despite the large and growing evidence base that a variety of forms of psychotherapy are effective treatments for a range of problems, we are likely to continue to see a decreasing availability of the already diminishing resources that can provide high quality psychotherapy for those who can potentially benefit from it.

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