Post by Former NIMH Director Thomas Insel: A Decade of Perspective
In another week or so, I will have been director of NIMH for ten years. This is longer than any previous director dating back to the inaugural director, Bob Felix, who served from 1949 to1964. In leadership, longevity is not necessarily a virtue but it does guarantee perspective. A decade is long enough to witness two cycles of five-year grants, several generations of post-doctoral fellows, and turnover in most of the leadership of NIH and NIMH.
Starting at NIMH in 2002, one of my first meetings was with the chair of the House Labor-DHHS Appropriations Subcommittee, a veteran congressman from the Midwest. He began by asking me what was new at NIMH. I told him proudly about a paper from an NIMH grantee just published in Nature. He smiled and wondered, with a little too much irony, “How’s that help my folks in Ohio?” It’s a question that I have heard in one form or another from parents, providers, and patients throughout the past ten years. And, it’s a question that I ask myself—now on a daily basis—because NIMH is a public health agency. That means our value is ultimately measured by patients not by papers.
The perspective that comes with longevity is really about understanding how to balance the urgent public health need of patients and families with the slow and serendipitous path of science. Science sometimes seems to produce more questions than answers. In a world of mental anguish where “time matters,” it may be hard to accept that science is a marathon not a sprint. But a decade of leading NIMH only confirms my belief that rigorous, unbiased science is the best answer—really the only hope—for delivering the preventions and cures needed so urgently for people with mental disorders. It takes more than a decade, but there are no reliable short cuts.
For me the key message of science is not only hope but humility. Science teaches us to distrust our perceptions. We see and feel the world as flat. We perceive the sun revolving around the earth. We believe we are unbiased—that all of us are above average. Science defies the wisdom of the crowd. A quote by Bertolt Brecht from his Life of Galileo says it best: “The aim of science is not to open the door to infinite wisdom but to set some limit to infinite error.”
But science is much more than myth busting and ego puncturing. Science is mind expanding, showing us things so weird and wonderful they are not only beyond our perceptions but beyond our imagination. Over this past decade, genomics and neuroscience have taken us to places much stranger than science fiction. Three examples from the just last few months: (1) in terms of cell number and DNA load, we are more microbial than human1, (2) our genomes are littered with more mutations and more biological signals than anyone could have guessed2, and (3) mothers have cells in their brains that appear to be from the babies they have carried in utero3. This last discovery—described with the wonderful name of “microchimerism” in the brain—is astonishing. Before coming to NIMH I spent a decade studying the neurobiology of parenthood. While many of us talked about motherhood as a biological transition, believe me, nobody imagined anything as weird as an infant’s stem cells populating the brains of his or her mother. The British biologist J.B.S. Haldane got it just right in his book, Possible Worlds: “The universe is not only queerer than we suppose, but queerer than we can suppose.”
What does cool science mean for a homeless man with schizophrenia, an autistic child without language, or a soldier with PTSD? How do these mind-expanding discoveries help the folks in Ohio? At the very least, science keeps us honest and humble, making sure that we reject or at least challenge our intuitions about cause and treatment. Much of the history of psychiatry is tragically about blaming parents or sometimes blaming the person unlucky enough to become ill. Science can falsify these presumptions about cause—setting a limit to infinite error. And it helps us to set a higher bar for treatment, recognizing that current treatments are, at best, stepping stones to preventions and cures.
But there is a more fundamental role for science, which is nothing less than the quest for understanding our world. The homeless man with schizophrenia, the non-verbal child with autism, and the soldier with PTSD need services and treatment, but also understanding—because the quest for understanding spawns compassion, intimacy, and even wonder. The past decade at NIMH has been all about this quest, recognizing that after six decades, we are still at the very beginning of understanding the world of mental illness. There really are no short-cuts.
But I believe we are on the right path, trying to solve mysteries from neurons to neighborhoods and the vast landscape in between, with tools that get better every year. Medicine recently has had spectacular successes: brilliant science has transformed how we can prevent or cure heart disease, AIDS, and now several forms of cancer. We are not there yet for any of the serious mental disorders that NIMH has pledged to prevent and cure. But make no mistake, these are mysteries with a solution. Genomics and neuroscience are revolutionizing the search with powerful new tools that will yield biomarkers, new diagnostics, and better treatments. It is when we hit a new level of understanding measured by patients, not papers, that there is truly a breakthrough. I know that “time matters.” I also know that science is not a sprint. But the marathon is not endless. At this ten-year mark, when I am breathless, it is not from the distance traveled or seeing the distance ahead, but from the challenge of keeping up with the progress around me.
There is an old story, no doubt apocryphal, that President Kennedy asked a White House gardener to plant a great oak tree outside the rose garden. The gardener hesitated, explaining it would take decades for the oak to grow into a great tree. Kennedy responded, “Then there is not a moment to waste. Plant it now.”
Because “time matters” for people with mental illness and because there are no shortcuts for our science, there is truly not a moment (or a dollar) to waste.