In an article in The New York Times last week, “Psychiatry’s Guide is Out of Touch with Science, Experts Say,” science reporters, Pam Belluck and Benedict Carey, describe an important new initiative by the National Institute of Mental Health (NIMH), the largest source of federal funding for mental health research. The new initiative criticizes the soon to be published fifth edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM-5), offering 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. I am ambivalent, some significant problems are being addressed, but other problems may be exacerbated in this latest development in the politics of the sciences of the mind and the brain.
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 and has been discussed extensively in important media outlets including The New York Times. Previous editions of the DSM have also received 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 chair of the task force that developed DSM-4) and Robert Spitzer (who chaired the DSM-3 task force). Criticisms of DSM-5 are similar in nature (if not intensity) to those leveled at both DSM-4 and DSM-3. For example, claims for the degree of reliability of diagnostic categories are exaggerated, 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 over prescribe 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.
The NIMH has held a series of workshops over the past 18 months, to develop the RDoc framework described in Belluck & Carey’s article. This has been motivated by factors including the intensity of the controversy about DSM-5, the accumulating evidence that the new generation of psychiatric medications is not delivering on its initial promise, and in all probability, the Obama administration’s avowed intention of investing 100 million dollars in the field of brain science research. This shift in NIMH policy has taken place so recently 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, the policy change is nothing to celebrate. Although I have long been a critic of the DSM system, the changed policy 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” (quoted 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, privileging the biological over the psychological, emotional and social. An important consequence of this trend has been that the proportion of NIMH funding allocated to psychotherapy research and other psychosocial interventions relative to the brain sciences has been consistently diminishing over time.
The new NMIH paradigm for research 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: 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 investigation. 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.
In concrete terms the 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. People will suffer as a consequence.
P.S. “Shortcomings of a Psychiatric Bible”: critical notes on a New York Times editorial.
A May 12thNew York Times editorial titled: “Shortcomings of a Psychiatric Bible” is both revealing and distressing. After briefly discussing the recent National Institute of Mental Health (NIMH) decision to replace DSM-5 with their new Research and Diagnostic Criteria as a guiding framework for funding future research, the editors conclude with the following assertion:
“The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain. That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for. And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.”
This conclusion reflects an unquestioning acceptance of what has become the received wisdom that further advancement of our understanding of both the etiology and treatment of mental health problems is completely dependent on our ability to accurately map out the associated brain chemistry and neural circuitry. This belief is in keeping with the disease model of psychiatry, assuming that both the underlying causes and relevant targets for treatment are biological in nature. This assumption was also one of the important factors that led to the major revision of the Diagnostic and Statistical Manual for Mental Disorders (DSM-3) by the American Psychiatric Association in 1980 that laid the groundwork for the forthcoming fifth edition of the DSM that the NIMH is now abandoning, because of its lack of validity. NIMH is assuming that the failure to find relevant biological targets for psychiatry to focus on is the byproduct of a diagnostic system such as the DSM that cannot be assumed to reflect the way in which “nature is carved at the joints.” They are failing to consider the possibility of a more fundamental problem: the assumption that the underlying causes and relevant targets for treatment are exclusively biological.
It is one thing to hypothesize that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of brain activity or levels of neurotransmitters) or that symptom remission is associated with biological changes. It’s another to assume that the fundamental causes of psychological problems are always biological and that meaningful improvements in treatment will only take place when we can directly target the relevant brain chemistry. While it may be the case that biological factors play a more significant causal role in some psychological problems (e.g., schizophrenia) than others, the assumption that the major causal factor for mental health problems is always biological is a form of simplistic reductionism. Nevertheless, the disease model of mental illness has become the dominant narrative in our culture – a narrative that the Times editors quite unfortunately have accepted in an unquestioning fashion.
Jeremy D. Safran, Ph. D. is Co-Chair & Professor of Psychology, New School for Social Research; an advisory editor to the journal “Psychotherapy Research” and the author of Psychoanalysis & Psychoanalytic Therapies (American Psychological Association Publications, 2012).
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