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NEW YORK – Sitting amid assorted curios scattered throughout the windowless, paper-strewn office where for the past 2 decades he taught and conducted research at Columbia University and the New York State Psychiatric Institute, Joshua A. Gordon, MD, PhD, reflected on his next career move.
“I’m nervous. Excited. I am going in with an open mind,” said Dr. Gordon, who in mid-September became the new director of the National Institute of Mental Health.
Some are hoping such an “open mind” will result in a change of priorities from those favored by Dr. Gordon’s predecessor, Thomas Insel, MD.
“I’d like to say how welcome it is to have a new perspective at the helm of the NIMH,” said Roberto Lewis-Fernandez, MD, a Columbia University psychiatry professor, and director of the New York State Center of Excellence for Cultural Competence at the New York State Psychiatric Institute, both in New York City.
After 13 years as director, Dr. Insel left the NIMH at the end of 2015 to take a job with a former Google division now called Verily Life Sciences, an Alphabet company. A psychiatrist also trained as a neuroscientist, Dr. Insel often was a flash point over concerns that during his tenure – the longest in NIMH history – neuroscience eclipsed other important areas, such as patient support, basic clinical observation, and the biopsychosocial model of mental illness.
“There is absolutely nothing wrong with neuroscience research. It is entirely indispensable to the discovery of new treatments for mental illness,” said Dr. Lewis-Fernandez. “The critique is about the proportion of the portfolio that should be devoted to this work.”
Future vs. now
Emphasizing too much “gee whiz” science at the expense of research into psychosocial services has meant the NIMH has failed to fully use its immense power to address disparities in access to care, create strategies for cost-efficient, scalable interventions, and clarify best practices in sorely needed suicide prevention, according to an editorial written by Dr. Lewis-Fernandez and 19 other current and former members of the NIMH National Advisory Mental Health Council (Br J Psychiatry. Jun 2016;208[6]507-9). In the piece, the writers took issue with what they called the NIMH’s overemphasis on basic and translational neuroscience research, citing how since 2012, the institute has spent less than 15% of its roughly $1.5 billion annual budget on non-HIV/AIDS services and interventions.
Dr. Insel often responded to such criticism in his widely read blog, where he acknowledged the tension between meeting patients’ current needs and investing in future discoveries, but also said the gap between what is known about the brain and about mental illness versus what is unknown was “unconscionable.” In an effort to help right this wrong, Dr. Insel announced that the NIMH essentially would drop use of the Diagnostic and Statistical Manual of Mental Disorders in favor of the Research Domain Criteria (RDoC) project, a new classification system of mental illness incorporating genetics, imaging, cognitive science, and other fields. He also made frequent media appearances to explain the institute’s participation in the 20-year, cross-disciplinary $4.5 billion Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative. In addition, he championed the Human Connectome Project to map neurocircuitry.
‘Return to its roots’
Others believe that neuroscience notwithstanding, the institution, founded in 1949, is not hewing to its intended purpose, which is to “transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure,” according to its mission statement.
“The NIMH needs to return to its roots: studying, taking care of, and hopefully curing seriously mentally ill patients. That should be the most important piece of its agenda,” said practicing psychiatrist David Pickar, MD. Between 1977 and 1999, Dr. Pickar held a variety of NIMH intramural research division posts, including section chief for clinical neuroscience studies and chief of experimental therapeutics. Currently, he is an adjunct professor of psychiatry at Johns Hopkins University, Baltimore.
Dr. Gordon said such clinical research can be achieved through grants to external investigators. “We have limited resources at the NIMH when you consider how much money is spent overall on mental health care,” Dr. Gordon said. Four NIMH divisions are dedicated to overseeing extramural research, compared with one intramural research division.
In a breakdown of NIMH spending between 2005 and 2014, Dr. Insel wrote that, when adjusted for biomedical inflation, the institute’s overall budget remained virtually flat since 2003. And while the scientific scope of grants funded has not changed much, “from molecular neuroscience to strategies of community care,” what has changed is the proportion of spending on certain areas as “scientific opportunities have evolved,” Dr. Insel wrote.
This has meant a 28% increase in spending for the neuroscience and basic behavioral science division, up from 2% in 2005. That number reflects spending on the BRAIN initiative and on genomics. An additional 25% is spent on translational research, and only 10% – a reduction of about 17% since 2011 – on traditional services research and clinical trials, reflecting a preference for “experimental medicine trials that will be more informative of disease mechanisms,” Dr. Insel wrote. From 2011 to 2014, external spending on clinical trials dropped, from $110.3 million to $75.3 million. Monies spent on services research remained virtually steady at about $67 million annually.
Clinical experience matters
Although Dr. Gordon is celebrated for his neuroscientific work in optogenetics – an emerging technology not yet tested in humans that, if feasible, will allow scientists to turn on or off neurocircuits implicated in a range of mental diseases, including schizophrenia – he has maintained a clinical psychiatric practice for most of his career, whereas Dr. Insel has not.
This is seen by many as a sign Dr. Gordon might be the man to bridge the divide among proponents of less neuroscience and more services or clinical research.
“We trust that Dr. Gordon’s clinical training and exposure to day-to-day challenges of people living with mental illness will impress upon him the need to balance the NIMH’s research portfolio,” said Dr. Lewis-Fernandez, also director of the Hispanic Treatment Program at the New York State Psychiatric Institute.
Having one foot each in clinical practice and bench science might even have enhanced his candidacy for the directorship.
“While it is not necessary to have a neuropsychiatry background to be a visionary, Dr. Gordon’s background enables him to have an exceptionally broad vision of the field of mental health that spans cutting-edge science to clinical care,” Dr. Gordon’s new boss, National Institutes of Health director, Francis Collins, MD, PhD, said in an interview..
Firmly stating his commitment to neuroscience’s “tremendous potential” to improve patient care, Dr. Gordon said he believes most clinicians do not struggle to recognize various states of mental illness, but that they do run into fragmented care, which hurts their practice. “The biggest impact [the NIMH] would have during or immediately after my term would be figuring out how to get therapies that we know already work implemented either better or more uniformly.”
He cited as an example, the Recovery After an Initial Schizophrenia Episode (RAISE) program, an early intervention strategy that involves integrated care in an outpatient setting aimed at reducing the duration between first-episode psychosis and treatment. Widely considered an NIMH success story when compared with treatment as usual, both in terms of actual outcome data and patient satisfaction, Dr. Gordon said he believes it demonstrates how the NIMH can help mend fragmentation of mental health services. Using RAISE as a model “can have an impact in relatively targeted spheres,” he said.
Neither such systems engineering, nor Dr. Insel’s “experimental medicine,” should be the NIMH’s primary activity, according to Dr. Pickar. “Early intervention in the outpatient setting is lovely, but it’s not going to help research too terribly much. If you work directly with patients, you will be forced in the right direction,” he said.
As many as 40 patient beds per day were dedicated to clinical observation and treatment of patients with serious mental illness during his tenure, according to Dr. Pickar. In the past year, NIMH patient beds have totaled 24 with an average daily census of 92%, 8 of which are for pediatric-focused research. Often, beds are shared with other institutions such as the National Institute on Alcohol Abuse and Alcoholism, according to an NIMH spokesperson.
The combined reduction in both intra- and extramural clinical research does not bode well for patients, Dr. Pickar said. “Every advance in understanding the biology of serious mental illness starts with the clinical phenomena. That has gotten lost.”
Part of a bigger plan
Decisions over the NIMH’s priorities are not made in a vacuum, however. When asked about what aspects of clinical practice he expects to be the focus during Dr. Gordon’s tenure, Dr. Collins pointed to the presidential directive for precision medicine, saying he believes that eventually mental health diagnoses will “incorporate all of the information coming out of genetics, neuroscience, and behavioral science ... following the model of what is becoming the standard for cancer and heart disease.”
Research into the prevention of comorbid medical disorders in mental illness, and into ketamine as a rapidly acting, novel depression treatment, are important to the NIMH’s short-term focus, Dr. Collins said. But he also stressed that the quality of psychosocial treatments is “another very important area,” as is expanding access to treatment and reducing mental health disparities.
To wit, just days after Dr. Gordon assumed NIMH leadership, “Psychosocial Research at NIMH: A Primer” appeared on the institute’s website. Written by numerous staffers from across the NIMH, and overseen by interim director Bruce Cuthbert, PhD, the “primer” reiterates a commitment to neuroscience and the RDoC, while detailing how it is focused on patients’ needs now. There is a particular emphasis on expanded use of digital technologies to screen for and treat a variety of mental illnesses, and on the measurement of behavior, cognitive/affective processes, and patient self-reports as conducted by the NIMH’s cross-disciplinary mental health council. The document was created in response to pressure from researchers and clinicians alike who asked the institute for clarification and reassurance about the NIMH’s attention to psychosocial concerns, according to an NIMH spokesperson.
This kind of dialogue over roadblocks to care will characterize his leadership, particularly at the start, Dr. Gordon said. He encourages clinicians to communicate directly with him, particularly around where they think money should be spent in the short term. “I would love to hear that from them,” he said.
Although Dr. Gordon said that Dr. Insel hasn’t specifically told him what to do, he has offered his counsel. “I [have spoken] with Tom several times. He has given me wonderful advice, and the best piece was to take the first 6 months to a year and just listen. That’s what I intend on doing.”
On Twitter @whitneymcknight
NEW YORK – Sitting amid assorted curios scattered throughout the windowless, paper-strewn office where for the past 2 decades he taught and conducted research at Columbia University and the New York State Psychiatric Institute, Joshua A. Gordon, MD, PhD, reflected on his next career move.
“I’m nervous. Excited. I am going in with an open mind,” said Dr. Gordon, who in mid-September became the new director of the National Institute of Mental Health.
Some are hoping such an “open mind” will result in a change of priorities from those favored by Dr. Gordon’s predecessor, Thomas Insel, MD.
“I’d like to say how welcome it is to have a new perspective at the helm of the NIMH,” said Roberto Lewis-Fernandez, MD, a Columbia University psychiatry professor, and director of the New York State Center of Excellence for Cultural Competence at the New York State Psychiatric Institute, both in New York City.
After 13 years as director, Dr. Insel left the NIMH at the end of 2015 to take a job with a former Google division now called Verily Life Sciences, an Alphabet company. A psychiatrist also trained as a neuroscientist, Dr. Insel often was a flash point over concerns that during his tenure – the longest in NIMH history – neuroscience eclipsed other important areas, such as patient support, basic clinical observation, and the biopsychosocial model of mental illness.
“There is absolutely nothing wrong with neuroscience research. It is entirely indispensable to the discovery of new treatments for mental illness,” said Dr. Lewis-Fernandez. “The critique is about the proportion of the portfolio that should be devoted to this work.”
Future vs. now
Emphasizing too much “gee whiz” science at the expense of research into psychosocial services has meant the NIMH has failed to fully use its immense power to address disparities in access to care, create strategies for cost-efficient, scalable interventions, and clarify best practices in sorely needed suicide prevention, according to an editorial written by Dr. Lewis-Fernandez and 19 other current and former members of the NIMH National Advisory Mental Health Council (Br J Psychiatry. Jun 2016;208[6]507-9). In the piece, the writers took issue with what they called the NIMH’s overemphasis on basic and translational neuroscience research, citing how since 2012, the institute has spent less than 15% of its roughly $1.5 billion annual budget on non-HIV/AIDS services and interventions.
Dr. Insel often responded to such criticism in his widely read blog, where he acknowledged the tension between meeting patients’ current needs and investing in future discoveries, but also said the gap between what is known about the brain and about mental illness versus what is unknown was “unconscionable.” In an effort to help right this wrong, Dr. Insel announced that the NIMH essentially would drop use of the Diagnostic and Statistical Manual of Mental Disorders in favor of the Research Domain Criteria (RDoC) project, a new classification system of mental illness incorporating genetics, imaging, cognitive science, and other fields. He also made frequent media appearances to explain the institute’s participation in the 20-year, cross-disciplinary $4.5 billion Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative. In addition, he championed the Human Connectome Project to map neurocircuitry.
‘Return to its roots’
Others believe that neuroscience notwithstanding, the institution, founded in 1949, is not hewing to its intended purpose, which is to “transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure,” according to its mission statement.
“The NIMH needs to return to its roots: studying, taking care of, and hopefully curing seriously mentally ill patients. That should be the most important piece of its agenda,” said practicing psychiatrist David Pickar, MD. Between 1977 and 1999, Dr. Pickar held a variety of NIMH intramural research division posts, including section chief for clinical neuroscience studies and chief of experimental therapeutics. Currently, he is an adjunct professor of psychiatry at Johns Hopkins University, Baltimore.
Dr. Gordon said such clinical research can be achieved through grants to external investigators. “We have limited resources at the NIMH when you consider how much money is spent overall on mental health care,” Dr. Gordon said. Four NIMH divisions are dedicated to overseeing extramural research, compared with one intramural research division.
In a breakdown of NIMH spending between 2005 and 2014, Dr. Insel wrote that, when adjusted for biomedical inflation, the institute’s overall budget remained virtually flat since 2003. And while the scientific scope of grants funded has not changed much, “from molecular neuroscience to strategies of community care,” what has changed is the proportion of spending on certain areas as “scientific opportunities have evolved,” Dr. Insel wrote.
This has meant a 28% increase in spending for the neuroscience and basic behavioral science division, up from 2% in 2005. That number reflects spending on the BRAIN initiative and on genomics. An additional 25% is spent on translational research, and only 10% – a reduction of about 17% since 2011 – on traditional services research and clinical trials, reflecting a preference for “experimental medicine trials that will be more informative of disease mechanisms,” Dr. Insel wrote. From 2011 to 2014, external spending on clinical trials dropped, from $110.3 million to $75.3 million. Monies spent on services research remained virtually steady at about $67 million annually.
Clinical experience matters
Although Dr. Gordon is celebrated for his neuroscientific work in optogenetics – an emerging technology not yet tested in humans that, if feasible, will allow scientists to turn on or off neurocircuits implicated in a range of mental diseases, including schizophrenia – he has maintained a clinical psychiatric practice for most of his career, whereas Dr. Insel has not.
This is seen by many as a sign Dr. Gordon might be the man to bridge the divide among proponents of less neuroscience and more services or clinical research.
“We trust that Dr. Gordon’s clinical training and exposure to day-to-day challenges of people living with mental illness will impress upon him the need to balance the NIMH’s research portfolio,” said Dr. Lewis-Fernandez, also director of the Hispanic Treatment Program at the New York State Psychiatric Institute.
Having one foot each in clinical practice and bench science might even have enhanced his candidacy for the directorship.
“While it is not necessary to have a neuropsychiatry background to be a visionary, Dr. Gordon’s background enables him to have an exceptionally broad vision of the field of mental health that spans cutting-edge science to clinical care,” Dr. Gordon’s new boss, National Institutes of Health director, Francis Collins, MD, PhD, said in an interview..
Firmly stating his commitment to neuroscience’s “tremendous potential” to improve patient care, Dr. Gordon said he believes most clinicians do not struggle to recognize various states of mental illness, but that they do run into fragmented care, which hurts their practice. “The biggest impact [the NIMH] would have during or immediately after my term would be figuring out how to get therapies that we know already work implemented either better or more uniformly.”
He cited as an example, the Recovery After an Initial Schizophrenia Episode (RAISE) program, an early intervention strategy that involves integrated care in an outpatient setting aimed at reducing the duration between first-episode psychosis and treatment. Widely considered an NIMH success story when compared with treatment as usual, both in terms of actual outcome data and patient satisfaction, Dr. Gordon said he believes it demonstrates how the NIMH can help mend fragmentation of mental health services. Using RAISE as a model “can have an impact in relatively targeted spheres,” he said.
Neither such systems engineering, nor Dr. Insel’s “experimental medicine,” should be the NIMH’s primary activity, according to Dr. Pickar. “Early intervention in the outpatient setting is lovely, but it’s not going to help research too terribly much. If you work directly with patients, you will be forced in the right direction,” he said.
As many as 40 patient beds per day were dedicated to clinical observation and treatment of patients with serious mental illness during his tenure, according to Dr. Pickar. In the past year, NIMH patient beds have totaled 24 with an average daily census of 92%, 8 of which are for pediatric-focused research. Often, beds are shared with other institutions such as the National Institute on Alcohol Abuse and Alcoholism, according to an NIMH spokesperson.
The combined reduction in both intra- and extramural clinical research does not bode well for patients, Dr. Pickar said. “Every advance in understanding the biology of serious mental illness starts with the clinical phenomena. That has gotten lost.”
Part of a bigger plan
Decisions over the NIMH’s priorities are not made in a vacuum, however. When asked about what aspects of clinical practice he expects to be the focus during Dr. Gordon’s tenure, Dr. Collins pointed to the presidential directive for precision medicine, saying he believes that eventually mental health diagnoses will “incorporate all of the information coming out of genetics, neuroscience, and behavioral science ... following the model of what is becoming the standard for cancer and heart disease.”
Research into the prevention of comorbid medical disorders in mental illness, and into ketamine as a rapidly acting, novel depression treatment, are important to the NIMH’s short-term focus, Dr. Collins said. But he also stressed that the quality of psychosocial treatments is “another very important area,” as is expanding access to treatment and reducing mental health disparities.
To wit, just days after Dr. Gordon assumed NIMH leadership, “Psychosocial Research at NIMH: A Primer” appeared on the institute’s website. Written by numerous staffers from across the NIMH, and overseen by interim director Bruce Cuthbert, PhD, the “primer” reiterates a commitment to neuroscience and the RDoC, while detailing how it is focused on patients’ needs now. There is a particular emphasis on expanded use of digital technologies to screen for and treat a variety of mental illnesses, and on the measurement of behavior, cognitive/affective processes, and patient self-reports as conducted by the NIMH’s cross-disciplinary mental health council. The document was created in response to pressure from researchers and clinicians alike who asked the institute for clarification and reassurance about the NIMH’s attention to psychosocial concerns, according to an NIMH spokesperson.
This kind of dialogue over roadblocks to care will characterize his leadership, particularly at the start, Dr. Gordon said. He encourages clinicians to communicate directly with him, particularly around where they think money should be spent in the short term. “I would love to hear that from them,” he said.
Although Dr. Gordon said that Dr. Insel hasn’t specifically told him what to do, he has offered his counsel. “I [have spoken] with Tom several times. He has given me wonderful advice, and the best piece was to take the first 6 months to a year and just listen. That’s what I intend on doing.”
On Twitter @whitneymcknight
NEW YORK – Sitting amid assorted curios scattered throughout the windowless, paper-strewn office where for the past 2 decades he taught and conducted research at Columbia University and the New York State Psychiatric Institute, Joshua A. Gordon, MD, PhD, reflected on his next career move.
“I’m nervous. Excited. I am going in with an open mind,” said Dr. Gordon, who in mid-September became the new director of the National Institute of Mental Health.
Some are hoping such an “open mind” will result in a change of priorities from those favored by Dr. Gordon’s predecessor, Thomas Insel, MD.
“I’d like to say how welcome it is to have a new perspective at the helm of the NIMH,” said Roberto Lewis-Fernandez, MD, a Columbia University psychiatry professor, and director of the New York State Center of Excellence for Cultural Competence at the New York State Psychiatric Institute, both in New York City.
After 13 years as director, Dr. Insel left the NIMH at the end of 2015 to take a job with a former Google division now called Verily Life Sciences, an Alphabet company. A psychiatrist also trained as a neuroscientist, Dr. Insel often was a flash point over concerns that during his tenure – the longest in NIMH history – neuroscience eclipsed other important areas, such as patient support, basic clinical observation, and the biopsychosocial model of mental illness.
“There is absolutely nothing wrong with neuroscience research. It is entirely indispensable to the discovery of new treatments for mental illness,” said Dr. Lewis-Fernandez. “The critique is about the proportion of the portfolio that should be devoted to this work.”
Future vs. now
Emphasizing too much “gee whiz” science at the expense of research into psychosocial services has meant the NIMH has failed to fully use its immense power to address disparities in access to care, create strategies for cost-efficient, scalable interventions, and clarify best practices in sorely needed suicide prevention, according to an editorial written by Dr. Lewis-Fernandez and 19 other current and former members of the NIMH National Advisory Mental Health Council (Br J Psychiatry. Jun 2016;208[6]507-9). In the piece, the writers took issue with what they called the NIMH’s overemphasis on basic and translational neuroscience research, citing how since 2012, the institute has spent less than 15% of its roughly $1.5 billion annual budget on non-HIV/AIDS services and interventions.
Dr. Insel often responded to such criticism in his widely read blog, where he acknowledged the tension between meeting patients’ current needs and investing in future discoveries, but also said the gap between what is known about the brain and about mental illness versus what is unknown was “unconscionable.” In an effort to help right this wrong, Dr. Insel announced that the NIMH essentially would drop use of the Diagnostic and Statistical Manual of Mental Disorders in favor of the Research Domain Criteria (RDoC) project, a new classification system of mental illness incorporating genetics, imaging, cognitive science, and other fields. He also made frequent media appearances to explain the institute’s participation in the 20-year, cross-disciplinary $4.5 billion Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative. In addition, he championed the Human Connectome Project to map neurocircuitry.
‘Return to its roots’
Others believe that neuroscience notwithstanding, the institution, founded in 1949, is not hewing to its intended purpose, which is to “transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure,” according to its mission statement.
“The NIMH needs to return to its roots: studying, taking care of, and hopefully curing seriously mentally ill patients. That should be the most important piece of its agenda,” said practicing psychiatrist David Pickar, MD. Between 1977 and 1999, Dr. Pickar held a variety of NIMH intramural research division posts, including section chief for clinical neuroscience studies and chief of experimental therapeutics. Currently, he is an adjunct professor of psychiatry at Johns Hopkins University, Baltimore.
Dr. Gordon said such clinical research can be achieved through grants to external investigators. “We have limited resources at the NIMH when you consider how much money is spent overall on mental health care,” Dr. Gordon said. Four NIMH divisions are dedicated to overseeing extramural research, compared with one intramural research division.
In a breakdown of NIMH spending between 2005 and 2014, Dr. Insel wrote that, when adjusted for biomedical inflation, the institute’s overall budget remained virtually flat since 2003. And while the scientific scope of grants funded has not changed much, “from molecular neuroscience to strategies of community care,” what has changed is the proportion of spending on certain areas as “scientific opportunities have evolved,” Dr. Insel wrote.
This has meant a 28% increase in spending for the neuroscience and basic behavioral science division, up from 2% in 2005. That number reflects spending on the BRAIN initiative and on genomics. An additional 25% is spent on translational research, and only 10% – a reduction of about 17% since 2011 – on traditional services research and clinical trials, reflecting a preference for “experimental medicine trials that will be more informative of disease mechanisms,” Dr. Insel wrote. From 2011 to 2014, external spending on clinical trials dropped, from $110.3 million to $75.3 million. Monies spent on services research remained virtually steady at about $67 million annually.
Clinical experience matters
Although Dr. Gordon is celebrated for his neuroscientific work in optogenetics – an emerging technology not yet tested in humans that, if feasible, will allow scientists to turn on or off neurocircuits implicated in a range of mental diseases, including schizophrenia – he has maintained a clinical psychiatric practice for most of his career, whereas Dr. Insel has not.
This is seen by many as a sign Dr. Gordon might be the man to bridge the divide among proponents of less neuroscience and more services or clinical research.
“We trust that Dr. Gordon’s clinical training and exposure to day-to-day challenges of people living with mental illness will impress upon him the need to balance the NIMH’s research portfolio,” said Dr. Lewis-Fernandez, also director of the Hispanic Treatment Program at the New York State Psychiatric Institute.
Having one foot each in clinical practice and bench science might even have enhanced his candidacy for the directorship.
“While it is not necessary to have a neuropsychiatry background to be a visionary, Dr. Gordon’s background enables him to have an exceptionally broad vision of the field of mental health that spans cutting-edge science to clinical care,” Dr. Gordon’s new boss, National Institutes of Health director, Francis Collins, MD, PhD, said in an interview..
Firmly stating his commitment to neuroscience’s “tremendous potential” to improve patient care, Dr. Gordon said he believes most clinicians do not struggle to recognize various states of mental illness, but that they do run into fragmented care, which hurts their practice. “The biggest impact [the NIMH] would have during or immediately after my term would be figuring out how to get therapies that we know already work implemented either better or more uniformly.”
He cited as an example, the Recovery After an Initial Schizophrenia Episode (RAISE) program, an early intervention strategy that involves integrated care in an outpatient setting aimed at reducing the duration between first-episode psychosis and treatment. Widely considered an NIMH success story when compared with treatment as usual, both in terms of actual outcome data and patient satisfaction, Dr. Gordon said he believes it demonstrates how the NIMH can help mend fragmentation of mental health services. Using RAISE as a model “can have an impact in relatively targeted spheres,” he said.
Neither such systems engineering, nor Dr. Insel’s “experimental medicine,” should be the NIMH’s primary activity, according to Dr. Pickar. “Early intervention in the outpatient setting is lovely, but it’s not going to help research too terribly much. If you work directly with patients, you will be forced in the right direction,” he said.
As many as 40 patient beds per day were dedicated to clinical observation and treatment of patients with serious mental illness during his tenure, according to Dr. Pickar. In the past year, NIMH patient beds have totaled 24 with an average daily census of 92%, 8 of which are for pediatric-focused research. Often, beds are shared with other institutions such as the National Institute on Alcohol Abuse and Alcoholism, according to an NIMH spokesperson.
The combined reduction in both intra- and extramural clinical research does not bode well for patients, Dr. Pickar said. “Every advance in understanding the biology of serious mental illness starts with the clinical phenomena. That has gotten lost.”
Part of a bigger plan
Decisions over the NIMH’s priorities are not made in a vacuum, however. When asked about what aspects of clinical practice he expects to be the focus during Dr. Gordon’s tenure, Dr. Collins pointed to the presidential directive for precision medicine, saying he believes that eventually mental health diagnoses will “incorporate all of the information coming out of genetics, neuroscience, and behavioral science ... following the model of what is becoming the standard for cancer and heart disease.”
Research into the prevention of comorbid medical disorders in mental illness, and into ketamine as a rapidly acting, novel depression treatment, are important to the NIMH’s short-term focus, Dr. Collins said. But he also stressed that the quality of psychosocial treatments is “another very important area,” as is expanding access to treatment and reducing mental health disparities.
To wit, just days after Dr. Gordon assumed NIMH leadership, “Psychosocial Research at NIMH: A Primer” appeared on the institute’s website. Written by numerous staffers from across the NIMH, and overseen by interim director Bruce Cuthbert, PhD, the “primer” reiterates a commitment to neuroscience and the RDoC, while detailing how it is focused on patients’ needs now. There is a particular emphasis on expanded use of digital technologies to screen for and treat a variety of mental illnesses, and on the measurement of behavior, cognitive/affective processes, and patient self-reports as conducted by the NIMH’s cross-disciplinary mental health council. The document was created in response to pressure from researchers and clinicians alike who asked the institute for clarification and reassurance about the NIMH’s attention to psychosocial concerns, according to an NIMH spokesperson.
This kind of dialogue over roadblocks to care will characterize his leadership, particularly at the start, Dr. Gordon said. He encourages clinicians to communicate directly with him, particularly around where they think money should be spent in the short term. “I would love to hear that from them,” he said.
Although Dr. Gordon said that Dr. Insel hasn’t specifically told him what to do, he has offered his counsel. “I [have spoken] with Tom several times. He has given me wonderful advice, and the best piece was to take the first 6 months to a year and just listen. That’s what I intend on doing.”
On Twitter @whitneymcknight
