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.

The Fifth Inconvenient Truth

Thomas Insel, MD the current head of NIMH captured a few sound bites in a recent edition of Psychiatric News.  In it the following Inconvenient Truths were mentioned:

1.  The field has failed to “bend the curve” in the prevalence and cost of mental illness;

2.  More people are getting more treatment, but outcomes are not getting better.

3.  The current knowledge base is insufficient to ensure prevention, recovery, or cure for too many people with serious mental illness.

4.  A transformation of diagnostics and therapeutics is necessary to make significant progress in treating mental illness.

Any head of a politically funded agency has to carefully parse his or her rhetoric in a manner consistent with his main goals.  I would see his main goal as getting funding for NIMH and in that role he needs to speak to the politicians who hold the purse strings.  That is really the only reason why cost is included in his first sentence.  The cost estimates both within the United States and world wide have been calculated many times and they are staggering.  There are well known estimates of disability that show the disability due to mental illness and addictions are routinely in the top ten causes.  But what  about the cost of treatment?  The cost of treatment has been flat to decreased for about three decades now largely as a result of managed care rationing with a disproportionate hit being absorbed by psychiatric services.  I have argued repeatedly that cost needs to be taken off the table in these discussions at least until the mental health infrastructure gets on even par with cardiology or oncology.  The whole idea that you can produce equivalent results with practically no resources strikes me as absurd.  The only thing more absurd is that we are supposed to be even more cost effective.  Compared with the rest of medicine we are looking at cost effective in the rear view mirror.  We crossed into the "on the cheap" zone a long time ago.  As expected, cost effective is synonymous with low quality.  Since we have abandoned quality reviews with managed care we have abandoned that word.  A more appropriate observation would have been:

The field has failed to “bend the curve” in the prevalence and quality of care of mental illness.

The second issue is a brief lapse into rhetoric of vagueness.  Who is "the field" here?  Are we referring to psychiatry, other mental health professionals, primary care physicians who do 80% of the psychopharmacology,  or the managed care systems and systems with the same techniques that rigorously ration mental health care?   The meaning of the sentence changes dramatically by substituting each of those words.

To the second point on more treatment not leading to better outcomes it is fairly easy to show why this is the logical outcome of rationing.  I have posted many times about how inpatient psychiatry has become sham treatment based on dangerousness criteria and corporate priorities.  You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few.  You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse.  You don't need any research to show that when people do not get research based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better.  When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve.  Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time.

Dr. Insel's third point should read:

The current knowledge base is not used to ensure prevention, recovery, or cure for too many people with serious mental illness.

I am not by any means suggesting that it cannot be improved upon.  There is no place in medicine where that is not the case.  When services are globally rationed and we are still beating the drum about "cost-effectiveness" we cannot expect inmates to have access to DBT or GPM to treat their borderline personality disorder.  We cannot expect them to get exposure therapy to treat PTSD from psychological trauma.  We can also not expect managed care patients to get this from 2 or 3 sessions of crisis counseling when they need a more specific research based psychotherapy.

The fourth statement is the only one that I have no issue with.  It is a statement that is generally true for most chronic illnesses.  I have many posts here about asthma for example.  Asthma is an illness that many primary care physicians believe that they really have made inroads in treating.  It is a great comparison for mental illness and even chronic mental illness because the fact is that most asthmatics are chronically symptomatic despite treatment.  The reason is a combination of a biologically complex disease, partially understood disease mechanisms, and a medical treatment model that involves seeing the patient every 3-6 months and prescribing them medications that are often partially effective at best.  There is really minimal medical intervention beyond that except for acute hospitalizations.  That is the exact level of care that we provide for mental illness in this country.

A lot of people fault Dr. Insel for being an advocate of neuroscience.  I may be one of the few who does not.  As a student of the brain and brain plasticity things are incredibly complex.  As politics get projected onto that complex system - science is often left in the lurch.  People see the results of a complex situation simplified as a meta-analysis and see the results as supporting both ends of a political argument.  I would go back to the asthma example.  The signaling in that disease is much less complex than signaling in the brain and there are far fewer cell types involved.  Asthma endophenotypes followed the elaboration of endophenotypes in schizophrenia and so far nether has resulted in clinical innovation.  I would argue that the treatment outcomes in most mental illnesses are on par or better than the treatment of asthma.  And yet there is no national research administrator of Dr. Insel's stature talking about the lack of progress.  I think the reason is clear - there are not nearly as many political arguments projected onto asthmatics.

If I fault Dr. Insel for anything it is for not knowing what has happened to the mental health system of care in the USA.  It is not due to a lack of technology, but an obstruction of current technology transfer.  He is not alone in routinely ignoring this as the central problem with psychiatric services today.  Any number of people do and in the process usually promote their own theories of why we are mired in the current environement.

That Fifth Inconvenient Truth?  Must be obvious by now but in the event that it is not:

Ration mental health and addiction treatment, ignore current research proven treatments, and reduce treatment to the prescription of medications and poor outcomes will follow.

You can take that to the bank.


George Dawson, MD, DFAPA