Post by Former NIMH Director Thomas Insel: Thinking about 2014
I had not planned to add another posting to the “2014 predictions” blogosphere, but after reading Nicholas Kristof’s column in the New York Times, I can’t resist. Kristof, who has won two Pulitzer Prizes for reporting on social injustice, is perhaps best known for bringing international attention to human trafficking and the suffering in Darfur. In his first column of 2014 he tells readers, “Those of us in the pundit world tend to blather on about what happened yesterday, while often ignoring what happens every day. We stir up topics already on the agenda, but we falter at calling attention to crucial-but-neglected issues.” He invites readers to suggest crucial-but-neglected issues, but devotes the rest of his column to his own selection: mental illness.
One prediction for 2014: we will see Mr. Kristof’s first choice for a neglected issue that needs more attention actually get more attention. Other journalists are already planning feature stories on the needs of those with serious mental illness, either as a civil rights issue, a public health crisis, or an area of medicine requiring deeper understanding. The discussion will move away from violence and mental illness towards equity, access, and quality of care.
The end of 2013, as always, brought Science magazine’s breakthroughs of the year announcement.1 This year, 4 of the 10 (CRISPR, CLARITY, organoids, and sleep research) were either directly or indirectly funded by NIMH. Considering that Science evaluates breakthroughs in all areas of science from astronomy to the physics of subatomic particles, 4 of the 10 is encouraging. A decade ago when NIMH had a single project (genes for schizophrenia) identified in the top 10 we felt this was an unprecedented sign of progress. No question that 2013 was a banner year for scientific discovery at NIMH.
What scientific breakthroughs should we predict for 2014? If the recent past is a reasonable predictor, identification of new sources of genetic and epigenetic variation seems likely. My guess is that somatic mutation in the brain will turn out to be more prevalent than we have realized.2 New insights about circuit function and behavior will emerge. Brain areas which have been relatively neglected in recent years—the insula, thalamus, and even hypothalamus—should receive much needed attention in 2014. And, if the recently announced BRAIN initiatives begin to bear fruit, we should expect to learn much more about the diversity of cells in the brain, as neuroscientists use the tools of single cell biology to begin to define the taxonomy of neurons and glia. Research into the microbiome, the community of microorganisms that are part of all of our bodies, is shedding new light on many developmental disorders, and may also reveal some surprises in 2014.3
The great challenge for 2014 for NIMH will be bridging this unprecedented progress in discovery science and the increasingly urgent need for better diagnostics, better therapeutics, and better systems of care. In 2014, RDoC will need to develop from a concept to a working model, moving us beyond symptom-based diagnostics. In 2014, for our clinical trials to have greater impact, they will need to focus on mechanisms of illness and real-world outcomes, not simply statistical efficacy. And this year, with the completion of the RAISE (Recovery After an Initial Schizophrenia Episode) project and the analysis of NAPLS (North American Prodrome Longitudinal Study), we can expect to launch fully the EP3 (Early Prediction and Prevention of Psychosis) efforts, aimed at finding biomarkers for risk of psychosis and defining programs of care for both the prodrome and first episode of psychosis to ensure better outcomes.
What’s my greatest concern for 2014? As Mr. Kristof and others raise awareness about the urgent need for better care, we must not let the conversation begin and end with increasing access, reducing stigma, and fixing reimbursement. And we must not get stuck on the same arguments about over-diagnosis, over-medication, and over-involvement of the pharmaceutical industry; especially since, in some areas, the data demonstrate a several-year delay in diagnosis, widespread absence of treatment, and general loss of interest from the pharmaceutical industry.
This year, let’s remember that, as in the rest of medicine, we need to know more if we want to do better. Current diagnostic systems, based on symptoms and not biomarkers, are not good enough. Providing access to current treatments is necessary but not sufficient. For too many people, current treatments are not good enough—an inconvenient truth for those with cancer, dementia, and, yes, mental illness as well. Unless the nation invests in research, we will not have anything better to offer. We have understood the need to invest in research for cancer and we have recently recognized the need for a deeper understanding, better diagnostics, and effective treatments for dementia. Is 2014 the time to recognize that, as with so many other areas of medicine, we need to focus on science as well as service for those with mental illness?
A recent editorial has called for a “War on Mental Illness.”4 That feels like the wrong metaphor to me, but it speaks to the challenge and the kind of commitment required. As Mr. Kristof says, “So mental health gets my vote as a major neglected issue meriting more attention. It’s not sexy…but it is a source of incalculable suffering that can be remedied.” It’s the right sentiment for 2014.
1 Breakthrough of the year 2013. Science. 2013 Dec 20;342(6165):1443. doi: 10.1126/science.342.6165.1443.
2 Insel TR. Brain somatic mutations: the dark matter of psychiatric genetics? Mol Psychiatry. 2013 Dec 17. doi: 10.1038/mp.2013.168. Epub 2013 Dec 17.
3 Hsiao EY et al. Microbiota modulate behavioral and physiological abnormalities associated with neurodevelopmental disorders. Cell. 2013 Dec 19;155(7):1451-63. doi: 10.1016/j.cell.2013.11.024. Epub 2013 Dec 5.
4 Licinio J, Wong ML. Launching the 'war on mental illness'. Mol Psychiatry. 2014 Jan;19(1):1-5. doi: 10.1038/mp.2013.180.