The NIMH Director and the RDoC - The Politics and The Science

from: Insel TR, Cuthbert BN. Medicine. Brain disorders? Precisely. 

Science. 2015 May1;348(6234):499-500.

I caught this article about the RDoC criteria for classifying mental illnesses based on various non descriptive parameters and neuroscience in the journal Science a couple of weeks ago.  As any reader of this blog can attest, there is no stronger advocate for the role of neuroscience in current psychiatric practice and the future of psychiatry than me.  There has been media controversy on this subject and it is always difficult to determine how much real controversy exists and how much of it is just made up for the sake of media self promotion like much of the DSM-5 controversy was.  Reading through the article by Thomas Insel and Bruce Cuthbert  there are statements that can be taken at face value.  I think these statements are consistent with the position that clinicians in general are not very scientific and are also outright clueless in some areas.  This is a bias that I have certainly heard from other scientists and it does not serve the cause of science very well, especially if the goal is to advance neuroscience and bring everyone up to speed on that discipline.  Dr. Insel has presented his view that all of the trainees in the clinical neurosciences of psychiatry, neurology, and neurosurgery should rotate through a year or two of a shared neuroscience.  When I first heard him present it five years ago I thought it was a great idea.  In the time since and especially after getting a response from him, I think it is less clear.  It would be great if every department of psychiatry had neuroscientists on staff to teach neuroscience.  But they don't and there is also the problem of neuroscientists being focused on research rather than teaching.  On the other hand, there are plenty of bright people in those departments who know a lot about the brain.  It is a question of reconciling these two points to come up with the necessary infrastructure yet in this article the authors make it seem as if large clinical problems are not addressed and that clinicians are fumbling around with very crude assessment methods.

They list three articles as examples of the RDoC.  The most interesting of these articles is one from the American Journal of Psychiatry that proposes that computer abstracted data from hospital notes that is converted to RDoC criteria are better predictors of hospital length of stay (LOS) than DSM criteria.  Just considering that method my first impression was that there was a lot wrong with that picture.  First of all,  LOS data is tremendously skewed based on non-clinical practices.  All it takes is hospital case managers with some success in intimidating physicians to skew the data in favor of business rather than actual medical or psychiatric discharge decisions.  Second, the quality of data from inpatient settings is incredibly bad due to the toxic combination of electronic health records and government billing and coding regulations.  As a reviewer, I have seen thousands of inpatient records, some of them hundreds of pages in length and I have found EHR records are notoriously poor in information content.  And finally, I thought the RDoC was a new system designed to be dependent more on neuroscience than the DSM-5?  How does methodology that looks at this DSM biased, sketchy clinical data result in a RDoC diagnosis?  Looking at the graphic from the Science article at the top of this post, it is pretty clear that 3 out 5 data dimensions under "Integrated Data" are basically clinical data.  There is a smugness displayed in the report similar to what might be seen in a rant by an antipsychiatrist: "For now clinicians might be best advised simply to be aware of the usefulness of dimensional models to capture psychopathology."  and "This result should provide some reassurance to clinicians that their notes do contain relevant detail for deriving dimensional measures of illness; like Molière’s Bourgeois Gentlemen speaking prose without knowing it, clinicians may already speak some RDoC."

Really?

The average person I see has chronic insomnia and has had possible sleep terrors and nightmares in childhood along with social phobia.  At some point they developed either severe anxiety or depression, but they can't recall the sequence of events and they currently have both.   They typically think that they have had "manic episodes" and may have been diagnosed with bipolar disorder even though they don't know what a manic episode is.  All they know is that their symptoms have persisted usually without remission for the past 10 to 15 years.  Of course that is complicated by the fact that they have been using marijuana, alcohol, and opioids in excessive amounts since then,  they may not have a significant family history of psychiatric and addiction problems, and they have the expected childhood adversity and adult markers of psychological trauma and abuse.  Further, I know from talking to the same people in repeated initial evaluations over the years that they don't give the same history twice and rarely remember much about their medications or psychotherapy treatment.  Should I use a "placeholder diagnosis" (pejorative term from reference 4) or should I assume that I am dealing with the social phobia that the patient may have had in childhood?  The idea that an RDoC diagnosis is going to give me an answer to that question any better than a DSM-5 diagnosis is pure folly if you ask me.  At least until we get the promised neuroscientific markers promised by the NIMH.  In fact, the description of the RDoC in these articles is reminiscent of another technology that was supposed to diagnose mental illness and that was quantitative EEG or QEEG.  I know quite a lot about QEEG, because I purchased a machine in the 1980s after a promising article on the technology came out in the journal Science.  I researched it using highly skilled EEG techs and an expert in neurophysiology to run the protocols, and concluded the diagnoses that came from the computerized analysis of the tracing were no better than chance in terms of what patients presented with.  Like RDoC diagnoses, the computerized analysis of QEEG data was highly dependent on the input of clinical data collected by the clinician.  It allowed the clinician to add and subtract clinical variables and look at how the diagnosis varied.  

The staff and researchers at the NIMH need to decide if a superior and critical attitude toward physicians who use current clinical approaches and are successful with them is the best one.  It should be obvious from the above analysis that many of us are not as naive or as ignorant about science as they expect. My proposed solution would be a more collaborative approach including the following:

1.  Recruit and train neuroscience teachers - most of them are already out there.  For example much of what I teach to trainees interested in addiction and addiction medicine is neuroscience.  It is also much more realistic than waiting for every department to have access to neuroscience researchers and then expecting those researchers to teach in addition to doing research.  My guess is that every Psychiatry department already has faculty that teach neuroanatomy, pharmacology, brain science and neuroscience already and that most of them are not officially scientists.

2.  Make the reading list available online - the article refers to over 1,000 published articles that focus on the RDoC criteria.  These should be available though the National Library of Medicine web site along with other neuroscience articles of interest to psychiatrists.  An added bonus would be CME activity available for self study.

3.  Post a list of neuroscience modules and build on that list -  In a previous post, I posted two links to neuroscience modules through the NIMH.  I would put up two lists, one containing a growing list of modules and the second with a list of the neuroscience concepts that need to be illustrated.  This would be useful for psychiatrists, psychiatrists in training, and medical school professors hoping to make their basic science lectures more relevant, since many clinicians still seem to have difficulty understanding how neuroscience is important in psychiatry.

4.  Better graphics - make high resolution graphs that illustrate detailed brain anatomy and basic science available online for teachers.  Pulling this material together is often the most difficult part of the teaching job and it requires an intensive effort to not run afoul of copyright laws.   It would be easier to recruit neuroscience teachers if there are high quality teaching materials available.

5.  A neuroscience teaching blog - In addition to the NIMH staff posting the references, concepts and modules, an open teaching blog should also be available.  I would encourage it to be a platform for discussing concepts and how to present them to trainees.  Ideally, it would be a place for active dialogue about the concepts and teaching them.

I think that all of these measures would be helpful in building an infrastructure of neuroscience teachers, neuroscience teaching, and a mechanism for the widespread dissemination of this material in residency programs and in educational programs for practicing psychiatrists.  If the RDoC is in fact worthwhile, there is plenty of brainpower outside of the NIMH to figure that out.

It is the brainpower that is currently focused on coming up with solutions and resolving problems of incredible clinical complexity.  And that happens every day.

I plan to send these recommendation to Director Insel and see what he thinks.



George Dawson, MD, DFAPA

1: Insel TR, Cuthbert BN. Medicine. Brain disorders? Precisely. Science. 2015 May 1;348(6234):499-500. doi: 10.1126/science.aab2358. PubMed PMID: 25931539.

2: Casey BJ, Craddock N, Cuthbert BN, Hyman SE, Lee FS, Ressler KJ. DSM-5 and RDoC: progress in psychiatry research? Nat Rev Neurosci. 2013 Nov;14(11):810-4. doi: 10.1038/nrn3621. Review. PubMed PMID: 24135697.

3:  NIMH.  Research Domain Criteria

4:  McCoy TH, Castro VM, Rosenfield HR, Cagan A, Kohane IS, Perlis RH. A clinical perspective on the relevance of research domain criteria in electronic health records. Am J Psychiatry. 2015 Apr;172(4):316-20. doi: 10.1176/appi.ajp.2014.14091177. PubMed PMID: 25827030.

Supplementary 1:

The above figure is licensed through the American Association for the Advancement of Science - license number 3637270124183.

Neuroscience In Psychiatry Now - It Is A Lot Easier Than It Looks

I read the article "The Future of Psychiatry as Clinical Neuroscience. Why Not Now?" by Ross, Travis, and Arbuckle in JAMA Psychiatry and found little to disagree with.  I was in one of the venues a few years ago when Thomas Insel, Director of the NIMH talked about a clinical  neuroscience rotation for neurology, neurosurgery, and psychiatry residents to bring neuroscience to the clinical side of things.  Unfortunately he was a lot less enthusiastic about it when I sent him a follow up e-mail and at that time suggested it would probably have to wait for some time in the future.  

As a long time neuroscience enthusiast,  I have always found the reluctance to head in this direction puzzling.  On a historical basis, neuroscience has always has a prominent role in psychiatric theory.  One of the arguments against neuroscience has been that there are no clinical applications.  Even back in the day with Alzheimer, Nissl, Kraepelin and other German neuropsychiatrists were studying brain anatomy of patients in asylums, there were important correlations - most notably those consistent with both Alzheimer's Disease and Binswanger's Disease.  About two decades later, Constantin von Economo penned his treatise Encephalitis Lethargica - Its Sequelae and Treatment and described conditions that were relevant right up to the point that I started my training in the 1980s.

Being a practicing psychiatrist with an interest in neuroscience presents a variety of CME events ranging from behavioral neurology and developmental pediatric conferences in Boston to the annual Movement Disorders conference in Aspen.  There were the occasional very unique courses, like the brain dissection course run by the late Lennart Heimer, MD and a faculty of outstanding neuroanatomists.  But most of the neuroscience in psychiatry is typically packed into a course that focuses on the specialized diagnosis and treatment of specific disorders.  A good example would be the American Association of Geriatric Psychiatry (AAGP) courses that would include a detailed discussion of Alzheimer's pathology and vascular dementia and how they might not be that disparate at the microscopic level (that was also an ongoing debate in the movement disorder conferences).  In an AAGP event there would be 1 lecture out of 7 for that day devoted to neuroscience.  On the teaching level, neuroscience has always been there in the form of neurotransmitters, localization of cognitive and neuropsychiatric disorders associated with various brain lesion and insults, cell signaling, and plasticity.  In the past 20 years there has been an unprecedented integration of neurotransmitters and specific brain structures as seen in this diagram of the ventromedial prefrontal cortex.  

I have been fantasizing about a foundation and several years ago came up with the idea that it should fund neuroscience education in psychiatry.  This would be my preliminary plan:


1.  Contract with the top neuroscientists in psychiatry to come up with the syllabus.  

From the reviews in review edition of Academic Psychiatry (reference 4) there are already residency training programs that have come up with a systematic approach to this training.  There should be a place for all programs to post what neuroscientists and researchers consider the top areas for focus.  From the reviews mentioned in the above narrative it is very likely that there are fairly complete syllabi at this point but looking at the reviews in Academic Psychiatry they seem to be fairly disparate in terms of what faculty see as the most relevant.  The vignettes prepared by the NIMH (reference 2 and 3) are illustrative of what is possible.  If I was designing a curriculum, I would want every possible concept that could be illustrated in these vignettes and build the course work around that.


2.  Develop neuroscience teaching as a specialty.

I doubt that there are enough neuroscientists around to teach the subject to psychiatry residents.  A group dedicated to teaching neuroscience and neuroscientific formulations would be a logical approach.  There are currently plenty of nonscientist faculty with an interest and more than a passing knowledge of neuroscience.


3.  Develop a repository of graphics and teaching materials. 

There is no area of psychiatry that could benefit more from high quality graphics for teaching.  Current faculty engaged in teaching need to run a gauntlet of copyright related issues ranging from implicit copyright permission (yes you can use for teaching without going through Copyright Clearance Center) to repetitive licensing fees that are difficult to track.  All of those problems are from publishers controlling these rights and in some cases charging unrealistic amounts for reuse of some of these works.  Open access work is a potential solution but it is doubtful that enough graphics currently exist to illustrate key neuroscience principles.  A coalition of residency programs can potentially contract for the production of custom figures for a central repository that could be used in residency programs across the country.  There is already a precedent for this process with the psychopharmacology course available to residency programs from the American Society of Clinical Psychopharmacology (ASCP) who produce a large number of PowerPoints that are available to residency programs for a very reasonable fee.


5.  Don't forget about addiction science.

The field of addiction has contributed immensely to understanding how the brain functions.  In many cases psychiatry residents have minimal exposure to the treatment of substance use disorders and the associated syndromes and that could potentially strengthen both those areas in any residency program.



6.  Hold annual review courses. 

The field as it applies to psychiatry contains neuroscience spread across gatherings for psychopharmacology, geriatric psychiatry, general psychiatry, child and adolescent psychiatry, sleep medicine, addiction medicine and behavioral neurology.  There should be meetings across the country that focus on the necessary neuroscience and formulations presented by the top experts in the world with that focus.


7.  Suggested readings.

I try to keep up with Nature, Science, and Neuron and the Science Signaling series as a cost effective approach to learning new developments about neuroscience and whatever open access journals that seem to have the best content.  There are top journals that are too expensive or require memberships where the threshold is set for researchers and not teachers.  A good general approach to how to approach the literature would be very useful for most of the teachers and some of the expensive journals might offer packages for teachers rather than researchers.  I can recall that when I interviewed for residency positions and asked about department recommended reading lists there was only one department who provided one in those days.  I will let readers guess about which department that was.


8.  Reviewing imaging studies and teaching files.

Some of the best neuroanatomical preparation and training in my career came from reviewing imaging studies with radiologists, neuroradiologists, neurologists and neurosurgeons.  Current electronic medical records make viewing imaging studies easier than at any time in the past.  There is no better learning procedure than to organize findings, order the test, and confirm the problem.  That is possible currently if you treat a lot of patients with apparent lesions on imaging but functional imaging is becoming more available it has the potential to revolutionize psychiatric practice.  As an example, listen to the story called How To Cure What Ails You and an enthusiastic Eric Kandel talk about the importance of the anatomical substrate (reference 5) in psychiatric disorders.

These are some of my current ideas.  I look forward to the day that a neuroscientific formulation about what might be relevant is contained in the same paragraph that includes social and psychological formulations.  It will also put psychiatrists back where most of us belong - seeing people with the most difficult problems rather giving out advice on how to prescribe antidepressants.


George Dawson, MD, DFAPA




References:

1: Ross DA, Travis MJ, Arbuckle MR. The Future of Psychiatry as ClinicalNeuroscience: Why Not Now? JAMA Psychiatry. 2015 Mar 11. doi: 10.1001/jamapsychiatry.2014.3199. [Epub ahead of print] PubMed PMID: 25760896

2:  National Institute of Mental Health neuroscience and psychiatry modules. 2012a. Available at http://www.nimh.nih.gov/neuroscience-and-psychiatry-module/index.html. Accessed on March 16, 2015.

3:  National Institute of Mental Health neuroscience and psychiatry modules: 2012b. Available at http://www.nimh.nih.gov/neuroscience-and-psychiatry-module2/index.html. Accessed on March 16, 2015.

4:  Coverdale J, Balon R, Beresin EV, Louie AK, Tait GR, Goldsmith M, Roberts LW. Teaching clinical neuroscience to psychiatry residents: model curricula. Acad Psychiatry. 2014 Apr;38(2):111-5. doi: 10.1007/s40596-014-0045-7. Epub 2014 Feb 4. Review. PubMed PMID: 24493360.

5:  How To Cure What Ails You.  Radiolab  Accessed on March 17, 2015.


Supplementary:

The header to this article is all of my copies of The Biochemical Basis of Neuropharmacology and the book I consider to be its successor  Introduction to Neuropsychopharmacology.  New editions of BBN came out in 1970, 1974, 1978, 1982, 1986, 1991, 1996, and 2003.  The copy with the white cover in the middle (a little faded) was the first copy I owned.  In those days I wrote the year I purchased books in the front jacket and that year was 1984.  This book with its elegant little drawings and low purchase price served as an introductory neuroscience text to many classes of psychiatry residents.

What replaces DSM5? Whither RDoC?

"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.



With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years.  There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder.  That is where NIMH's Research Domain Criteria (RDoC) come in.

Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment.   For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains.  A very conservative estimate suggests that this alone will take take least one hour of testing.  There will probably need to be a lot of time and effort expended on determining when a person is testable.  An RDoC diagnosis will be both time and resource intensive.  It won't be a template or a checklist.

I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed.  After all,  this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness."  When the RDoC comes to fruition there will not just be one test.  There will be many tests.

Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors.  It is the current political culture that applies junk science to the management of the health care system.  It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country.  The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care.  The care they ration the most is for the treatment of mental illnesses and addictions.

Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology  currently uses to assess heart disease?  The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome.  Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.

You can't implement an RDoC in that environment.

George Dawson, MD, DFAPA