Five Questions With: Dr. Thomas R. Insel

Director of the National Institute of Mental Health talks about the decision to re-orient research away from the categories of mental illness defined by the DSM. More

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Five Questions With: Dr. Thomas R. Insel

"I SPENT most of the day talking to people here; Providence is a very exciting place."
Posted 5/20/13

Dr. Thomas R. Insel is the director of the National Institute of Mental Health, the world’s largest funder of research on mental disorders, with an annual $1.5 billion budget.

Insel created shock waves in the medical research community when he announced in his April 29 blog that NIMH will be re-orienting its research away from the categories of mental illness defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). He argued that while DSM has created a reliable dictionary labels and definitions, its weakness is in its lack of validity.

“Patients with mental disorders deserve better,” Insel said, explaining that NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive sciences in order to lay the foundation for a new classification system.

Providence Business News had a chance to sit down and talk with Insel after he gave the keynote talk, “Rethinking Mental Illness,” at Brown University Department of Psychiatry and Human Behavior’s research symposium on mental health sciences on May 9 at Butler Hospital, where he detailed the new research approach.

PBN: Your talk was forward-looking in terms of how research, diagnosis and treatment of mental illness needs to change. How responsive do you think the powers that be in the medical world are to making those changes? Have you encountered resistance?

INSEL: I think I am the powers that be. In terms of research, I control, or rather, I am in charge of NIMH’s $1.5 billion budget.

No, there hasn’t been much resistance. I think people realize we have to do something different, because what we’ve been doing has not really worked that well.

I did a blog last week about the fact that NMIH was going to move away from DSM for research. DSM is very helpful for clinical care; it’s all we’ve got, so you have to use it in the clinic for providers.

But for scientists, we want people to begin going beyond this classification by symptoms and get deeper into the biology at many different levels – genetics, imaging, and cognition.

The response [so far] was favorable. The New York Times picked this up [as a story] and it was, for a couple of days, the number one e-mailed story.

The response I got from e-mail was almost entirely positive.

People are excited and hopeful that we can now begin to do this. We could have said this a decade ago, but we didn’t have any way to do it. Today, we really do have the tools to say: what circuits are involved, what genes are involved, how does this all work,

PBN: Here in Providence, there are a number of potential building blocks to move things forward, such as the Prince Neurosciences Institute and the Brown Institute for Brain Science. Does Providence have the potential to be a hub for this kind of new thinking and research?

INSEL: Yes. I spent most of the day talking to people here; Providence is a very exciting place. What often inhibits other places are fiefdoms and ego-drive turf wars. Providence is a place that seems to be built largely on collaboration and teamwork.

That’s a really hopeful sign. What has happened here is that you have a great focus on systems neuroscience, studying systems within the brain at the level of circuitry.

There’s also a lot of expertise in human neuroscience, and a lot of collaboration between engineers, neuroscientists and clinical research.

I don’t know that there are many places [such as Providence] that can bring that level of collaboration together in the same way. I would say that this is really exciting place for the kind of work that I’m talking about.

PBN: During your talk, you discussed implementing a pilot program to treat schizophrenia in a more holistic manner, working with community health centers. Are any of those pilots here in Rhode Island. What makes community health centers an attractive place to try this new approach?

INSEL: I think there are 32 sites nationwide but none in Rhode Island. [The ability to introduce innovative0 programs at community centers] is very important. Treating schizophrenia is different than cancer care of even cardiovascular care. We’re talking about young people who are often still embedded within families, and who have a need for chronic support. This is not like an infectious disease where you have it for two weeks, and then you’re better.

Young people are going to being dealing with this for years, maybe for their whole life span. So, what you need to for the resources to be accessible, not just to the person with the disorder, but also to families. And, what you need is a suite of resources, not just medication. It’s family support, peer support, educational and occupational resources; all of those pieces are part of the package you need.

You have to build it around a patient–centered approach, giving the young person, often between 18 and 22, a role in deciding what they most want to use, what treatment will be most helpful.

PBN: Here in Rhode Island, there’s new data showing that the state has increasing high rates of mental health and substance abuse. At the same time, there appears to be a disconnect between the growing need and shrinking treatment options. Psychologists are facing reduced insurance rates for services and new limits on how much time they can spend with patients. It takes months to schedule an appointment with a child psychiatrist; most don’t take health insurance. A number of therapists have said that traditional therapy is being marginalized and drug maintenance therapy promoted. Is this part of a larger cost-cutting trend?

INSEL: We know that the use of anti-psychotic drugs has gone way up. And the use anti-depressants in the last decade has also gone up in the last decade, almost doubling.

It’s not clear that [this change] is associated with much better outcomes.

I think the lesson is that while medication is important, [when it is]as part of the treatment, a part of the overall treatment plan.

What worries me about those kinds of stories is that when you talk to people who who recover from these sorts of chronic illness, they most always tell you that [their recovery] is because of a relationship. It’s not, “Gosh, I took this pill, and it was like taking penicillin for my fever.” That’s not the way it works.

Most people struggle for months and sometimes years, and it’s the relationship that matters. Those relationships don’t always have to be with a physician or a psychologist, but it has to be with someone who is really committed to helping the patient.

With diabetes, you wouldn’t treat patients by just giving them pills; we understand that they need consulting around diet, activity and lifestyle. I don’t know why it is so much harder for people to understand that you need to treat chronic mental disorders in a similar fashion.

PBN: For a young physician, and for a young researcher, what are the kinds of new tools will they have because of the research changes you are advocating?

INSEL: For a young physician, in terms of clinical tools, we’re not there yet. I was talking really about research opportunities. The opportunities for research are fantastic at every level – stem cells, genetics, imaging. We’ve now got fantastic technology to be able to study the brain and its relationship to behavior. Also, there are opportunities to build the tools – that’s part of what the President’s brain mapping initiative is about.

But it’s important to manage expectations. We’re still talking about what we can do in a research environment. As with our experience with cancer and other areas of medicine, it starts with the science, then translates over to the clinic. We’ll get there, but we’re not there now.

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