Insel`s big bet

History shows that human beings have been slow to recognize and respond effectively to the challenges of behavioral health. While medical science began to make ever-accelerating leaps forward starting in the Age of Enlightenment, behavioral health has progressed much more slowly, with progress often triggered by individual theoretical breakthroughs. And, while names like Freud and Rogers are widely known and associated with mental health today, we may owe even more to people who aren’t household names.

Consider Emil Kraepelin. Building on the work of fellow Germans, Kraepelin proposed in the 1890s that psychiatry was a branch of medicine and that mental disorders could be observed, identified, and classified scientifically based on syndromes — recognized and repeatable patterns of symptoms. He was the first to recognize the fundamental difference between mood and thought disorders. This distinction, which came to be known as the ‘Kraepellian dichotomy,’ is in the bedrock of modern psychiatry and its “bible” — the Diagnostic and Statistical Manual of Mental Disorders.

While he placed great stock in the value of classifying mental illnesses, Kraepelin was also fascinated by the genetics and biology of the brain and sought, with his colleagues, to identify hereditary or physiological patterns associated with mental illness. Thus, for more than one hundred years, our understanding and treatment of mental illnesses — and addictions — has proceeded along two tracks. The DSM emerged and is now being released in its fifth major edition, while the study of brain physiology has proceeded alongside. The former provides the best practical treatment currently available, while the latter continues to seek the same genetic, biological, and neurophysiological clues that Kraepelin, his colleagues, and scores before and after have sought — “silver bullets” that treat mental illness as though it were diabetes or cure it the way “precision medicine” zaps a cancerous tumor.  

The recent announcement by Tom Insel, Director of the National Institutes of Mental Health (NIMH), to de-fund future DSM-based research in favor of greater investment in neuroscience research can’t be questioned on scientific grounds. In the long term, it is the scientific approach most likely to produce a “silver bullet.” 

What’s upsetting to many — in psychiatry, psychology, and throughout behavioral health — is that Insel’s announcement puts a lot more on the line than the long-term scientific promise of one course of research versus another. It can be seen — and will be used by opponents — as immediate reason to question the effectiveness and viability of the DSM, the only accepted mental health diagnostic system we currently have; the credibility of those who advocate for behavioral health on Capitol Hill; the value of the still-forming partnership forming between medicine and behavioral health; and perhaps even the “medical necessity” of providing or paying for certain behavioral health services.

In effect, Insel is making a one-sided bet, upsetting NIMH’s tradition of a balanced research approach in the hope that with more financial juice, neuroscience will accomplish in 10 years what it hasn’t accomplished in the last 110. The upside is tremendous, but so are the risks. And, chief among those risks is trading years of incremental, research-driven improvement in millions of lives and the credibility of the imperfect but viable diagnostic and treatment system in the DSM-5 against the unseen promise of something better sometime — perhaps a long time — into the future. 

Hope he's right.