Roberto Lewis-Fernández is a professor at the Columbia University Department of Psychiatry and the New York State Psychiatric Institute.
Over the summer, the National Institute of Mental Health got its first new director in 13 years. As Joshua Gordon settles into the top job at NIMH, one of his primary tasks should be to respond to the widespread perception that the agency — the world’s largest funder of mental-health research, with an annual budget of approximately $1.5 billion — has lost sight of its most fundamental mission: finding ways to ease the burden of mental illness for those affected by it today.
For the past decade, an increasing emphasis on neuroscience research has eclipsed this public-health mission, leaving a research void that results in unnecessary and protracted suffering in our communities.
Gordon is well situated to respond to this tension. With dual degrees as a psychiatrist and a neuroscientist, he is a clinician who treats patients suffering from serious mental illnesses as well as a basic science researcher who studies genetic mutations in the brains of mice for clues to the mechanisms of psychiatric disorders.
These are two ways of approaching the same goal: One improves the lives of individuals and families today, the other seeks a foundation for the treatments of tomorrow.
NIMH grant funding supports both approaches, but in recent years the balance has tipped heavily toward the science of tomorrow. This disproportionate focus on future discoveries neglects pressing public-health needs. It means we miss opportunities to conduct practical research that would teach us how to get effective, acceptable treatments to the people who need them right now. It means we fail to learn why people don’t accept or are never even offered medicines and therapies that we know work. It means we don’t identify the best ways to deliver care outside the lab and in the real world.
In the past, NIMH recognized the need for a diversified research portfolio. The urgency for research on overcoming barriers to care, testing new interventions and developing feasible ways to bring research findings into practice was balanced with research aimed at discovering the brain mechanisms behind psychiatric disorders and using this knowledge to develop treatments.
But this once well-diversified research portfolio has been increasingly narrowed. Since 2012, a full 85 percent of non-AIDS-related grant funding has been channeled to basic scientific research. That’s left less than a fifth of this money for research on treatments and services to enhance the lives of those suffering today. Such a disproportionate emphasis is as unwise an investment approach as a retirement portfolio made up only of high-risk investments. The research portfolio also needs investments with shorter-term yields, if more modest benefits. As with any investment portfolio, diversification is prudent.
Neuroscience research is crucial, but it is a long-term proposition. Its payoffs may be tremendous, but they are exploratory, and for every success there are many, many dead ends. The benefits of even the most successful breakthroughs may be generations away.
Our current needs are urgent. Suicide is a good example. Effective interventions exist — previous research has proved that — but we need research to learn how best to get them to people at risk. In the meantime, people who might have been saved die.
Knowledge of what works is a beginning only; demonstrating that depression can be lifted through a medication or therapy or proving that the hallucinations of a person with schizophrenia can be mitigated is important, but we also need research on how to get such effective treatments into practice. How do we make sure services can be implemented, organized and financed so that clinicians do the right thing at the right time? How do we identify and transcend barriers of culture, race, ethnicity, gender and sexual orientation? We know that poor people have grossly inferior access to mental-health care and suffer worse outcomes. How do we eliminate such disparities?
And, as in other areas of medicine, in mental health sometimes an ounce of prevention is the best cure. Preventive strategies can enhance resilience, particularly in young people, and help reduce the impact of the many mental illnesses that emerge during a person’s teens and 20s. NIMH support is needed for research in all of these areas.
This is why a group of 20 current and former members of the NIMH National Advisory Mental Health Council (the body that approves NIMH funding decisions and advises on its overall direction), myself among them, have called on NIMH to make a course correction in its funding priorities. Although we presented our position in a scientific journal, the issue of how NIMH balances its research portfolio deserves the attention of Congress and the public.
Public health has always been a cornerstone of the NIMH mandate. Basic science research must continue, of course, but Gordon should commit to restoring greater emphasis on research that will alleviate suffering and maximize recovery for people coping with mental illnesses right now.