When Joshua Gordon arrived in Washington in July to lead the National Institute of Mental Health, he was confronted with a long-simmering controversy. Inside and outside of NIMH, scientists and others in the field were divided over whether the largest funder of research into mental illness should be concentrating its grants on high-tech studies of possible future treatments, even cures, or on psychosocial research more likely to help the mentally ill more quickly.
Gordon's background suggested split loyalties. He was a professor of psychiatry at Columbia University Medical Center with a private practice, as well as a neuroscientist conducting genetic research at the New York State Psychiatric Institute.
The debate heated up during the tenure of Gordon's predecessor, Thomas Insel, who left the helm of the institute after 13 years. Insel emphasized neuroscience and urged a reshaping of how mental illnesses are classified. Rather than sticking with the long-used Bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, Insel endorsed an approach called RDoC, for Research Domain Criteria, which emphasizes research into genomics and brain imaging as well as behavior.
The question was whether Gordon would stay on that neuroscientific course or turn more toward research into patient support and psychosocial services.
Last week, The Washington Post sat down with Gordon to discuss where he hopes to take the NIMH.
(The interview has been edited for length and clarity.)
Q: Research into mental illness has yielded medications, especially anti-depressants, that are now decades old and less effective than was originally thought. How do you view the current state of mental health treatment?
A: All these off-label uses of any of our psychiatric medications result from desperation on the part of both patients and physicians who don't know what else to do for their patients . . . The evidence for any of them is nonexistent or minimal. But we don't have good alternatives. We don't have evidence-based treatments that really do the job. So that means that people turn to whatever can help them in a symptomatic way . . . It's a problem that's borne out of the fact that our treatments just don't work, or don't work well, for a substantial fraction of our patients.
Q: Neuroscientists like to say the brain is the most complicated object in the universe, but why has it been so difficult to find adequate treatments for most mental illnesses?
A: We'd like to be trying to treat the underlying condition whatever it is. But without knowing what that underlying condition really is about, we can't target things.
Q: How will Research Domain Criteria help that?
A: What I hope to do with our RDoC is make it more data-driven . . . to define what categories of behavior there are. And then try to define those categories in a very formalized way so that we can use those behaviors to drive a neurobiological understanding of where we are.
Q: In the meantime, how do we move forward to finding what does work?
A: I am placing a substantial chunk of my hope on the notion that if we can better define our illnesses, and in particular subgroups of patients who might respond better to one kind of treatment or another, then our treatments will become more efficacious for those subgroups. That's based partly on some beginnings of scientific evidence, partly out of desperation, but also based upon the experience of many, many of my colleagues as well as their data from clinical trials. Medications often work very, very well for a subset of patients. And the question is, how do you identify that subset? And we have some exciting ways that we think we're going to be able to do that. And the beginnings of some hope, I would say, in that area.
Q: How invested will NIMH be in continuing Thomas Insel's legacy?
A: I believe it's important to continue the RDoC experiment. I come at it a slightly different way than Tom did with a slightly different emphasis. And I also think it's important to continue for now what we call the experimental therapeutics approach, which is a change in the way we do clinical trials here. . . . So we ask investigators to hypothesize and demonstrate some mechanism for the way a treatment works and then do the clinical trial while measuring that mechanism.
Q: How did you react to the RDoC critics when you arrived and the argument that research into psychosocial contributors to mental illness was not getting the funding that the neuroscientific researchers were?
A: First and foremost, I felt the need to understand it. And we're still going through this process. But I wanted to first ask, is it true that we've been spending less on short-term investments than long-term investments than we have in the past? And I learned some interesting things along the way. We spend as much on clinical trials as the average for any of the institutes at NIH. [But] we are spending less on short-term investments now than we did 10 years ago. So having established the facts, the next question is what to do about it. And I think, on the one hand we've made tremendous investments in basic neuroscience that I think are paying off. On the other hand, we should be actively looking for opportunities to help people who are suffering now. And so that's something that we are actively engaged in. . . . We put out two initiatives around suicide prevention, meaning that if a grant comes in that we think is actually good science, even if it might not fit into the portfolio in what we've predefined in that area, then we make an effort to invest in that.