Instructions: A fictitious, familiar, yet incomplete NIMH press release appears below. Choose one term from each parenthesis to fill in each blank. You may select answers that reflect positions of the NIMH and/or assumptions of the biomedical model (listed first in each parentheses), or alternative answers based on science and/or reality (listed second). It’s up to you!
On the Verge of Revolutionizing Precision Medicine
by Hopefully Transforming Diagnosis
Since the publication of DSM-III in 1980, biomedical research has demonstrated that mental health problems are _____ (disorders of brain circuits1 ; psychological problems with largely unknown biological causes). Indeed, it has become an NIMH mantra to describe mental disorders as _____ (brain disorders2 ; caused by the complex interaction of biological, psychological, and environmental factors). Advances in neuroimaging and other cutting-edge biomedical technologies have revolutionized our understanding of the brain, thereby _____ (“completely alter[ing] the way we approach diagnosis3”; having no effect on how diagnoses are made) and leading to _____ (the development of safer and more effective biological treatments; no meaningful advances in biological treatments4). Mental health outcomes in the United States have _____ (improved; not improved5) alongside NIMH’s support of biomedical theories and treatments in preference to evidence-based psychosocial approaches. To illustrate, dramatic increases in the use of antidepressant, antipsychotic, and stimulant medications have witnessed a _____ (decrease; marked increase6) in the prevalence of Americans on federal disability for the mental disorders these medications treat. Mental health stigma has _____ (improved; not improved7) as Americans have come to adopt our position that mental health problems are biologically-based brain diseases. One mental disorder listed in DSM-IV, Rett’s Disorder, has even been conclusively shown to have a biological cause8. As a result, Rett’s Disorder has been _____ (heralded as proof in principle that mental disorders are biologically-based diseases; removed from the DSM-5 as a mental disorder and reclassified as a genetic disorder9).
Despite these developments, reliance on the DSM diagnostic system is limiting our progress. Now that DSM-5 has been published, it is clear that DSM diagnoses are _____ (not valid10; neither adequately reliable nor valid11). Mental disorders are diagnosed based solely on symptoms, and objective laboratory measures for DSM diagnoses do not exist. In the rest of medicine, symptom-based diagnosis is not credible and has been largely replaced by diagnosis based on objective laboratory tests. Our declaration that DSM diagnoses lack validity because they cannot be diagnosed with objective tests has been previously asserted by _____ (“anti- psychiatry” forces who “don’t want to improve mental healthcare12”; well-informed critics whom we have spent half a century attempting to discredit as “anti-psychiatrists” for making this same point13). Given that the DSM system provides the foundation for nearly all mental health diagnosis, billing, coercive treatment, forensics, and research in the United States, its lack of validity is a serious problem for _____ (biomedical researchers only14; our entire mental health system). The fact that DSM diagnoses do not have established biomarkers ____ (means we should redouble our efforts to discover the biological causes of mental health problems rather than consider the consequences of pursuing a failed paradigm; directly contradicts our Page 1longstanding position that mental disorders have recognized biological causes15).
Patients with mental disorders deserve better. That’s why NIMH has launched the Research Domain Criteria (RDoC) project. We are committed to _____ (demonstrating that mental disorders are real medical diseases that can be diagnosed with objective laboratory measures16; meeting the needs of Americans with mental health problems). Unfortunately, decades of biomedical research based on the DSM diagnostic system have not allowed scientists to _____ (discover the biological causes of mental disorders we assume exist; develop meaningful advances in diagnosis and treatment). Consequently, _____ (we must create a new diagnostic system that will hopefully lead to the discovery of biomarkers; mental health problems may not be brain diseases after all). Although science has not advanced to the point where a neuroscience-based classification is possible, we must nevertheless proceed as if genetics and neuroscience will someday inform diagnosis17. Therefore, the RDoC initiative will support research designed to achieve the failed goal of DSM-5: “translat[ing] basic and clinical neuroscience research relating brain structure, brain function, and behavior into a classification of psychiatric disorders based on etiology and pathophysiology18.”
RDoC is a necessary first step toward precision medicine in which assessment of “molecular signatures, neuroimaging patterns, [and] inflammatory biomarkers”19 may lead to “cures” for brain diseases like depression and anxiety20. Understanding the true nature of mental health problems like depression will require contributions from many sources, such as _____ (“genomics, epigenetics, electrophysiology, animal models, [and] clinical psychiatry21”; scientists from a variety of disciplines who study biological, psychological, and environmental contributions to mental health problems). Given that we estimated the arrival of “biodiagnosis” and “treatment of core pathology” in 201522, the need to uncover the biological causes of mental disorders is urgent if we are to retain our credibility.
The NIMH is optimistic that additional decades of biomedical research following the RDoC project will _____ (renew dwindling pharmaceutical industry interest in psychiatry23 and bolster psychiatry’s image as a clinical neuroscience discipline24; perpetuate the opportunity cost associated with dramatically underfunding empirically supported psychosocial approaches). Our confidence is based on the track record of biomedical research in the modern DSM era, which demonstrates that we are _____ (currently, perpetually24) on the verge of transformative breakthroughs that might revolutionize mental health treatment. Under the leadership of biological psychiatrist Thomas Insel, the NIMH is committed to a future in which all patients with mental disorders undergo expensive biological testing administered by psychiatrists in medical settings to facilitate the use of personalized biological treatments provided by psychiatrists.
The RDoC initiative is symbolic of the NIMH’s commitment to disproportionately support biomedical research over evidence-based psychosocial approaches like cognitive-behavioral therapy that are often at least as effective as medications in the short-term and more effective in the long-term, have no adverse biological effects, are less expensive, and are strongly preferred by patients. Psychological scientists are encouraged to submit grant proposals for the RDoC initiative, provided that their research is intended to demonstrate the biological underpinnings of psychological processes in order to facilitate the “power of biology to identify illnesses (Page 2) linked to pathophysiology” and “the development of more specific [biological] treatments17 .” Psychologists interested in having their research supported by NIMH in the current funding climate must understand that _____ ( “to be a leading clinical psychologist, you have to know cognitive science, you have to know the biological basis of behavior, you have to know neuroscience, you have to know a fair amount of genetics25”; psychological research is not valued unless it involves the assessment of biological variables). We leave it to the profession of clinical psychology to deal with the consequences of our virtual requirement that psychological scientists must conduct neuroscience research if they wish to be supported by the NIMH.
Although three decades of NIMH biomedical research funded by billions of taxpayer dollars have failed to discover reliable biomarkers or produce safer and more effective biological treatments, we are optimistic that additional decades of biomedical research will validate our faith in this approach. Indeed, we have just allocated $40 million in 2014 to the BRAIN initiative, which focuses on “advancing our technological capabilities for understanding how circuits of interacting neurons function to create behavior, with the ultimate goal of improving our scientific foundation for the diagnosis and treatment of brain disorder26”. The NIMH looks forward to a future in which advances in biomedical research lead to biological tests and cures for brain diseases. In the meantime, we ask that individuals with mental health problems who have difficulty accessing safe, effective, and affordable interventions wait patiently while neuroscientists go about their work.
1 Insel, T. R. (2010). Faulty circuits. Scientific American, 302, 44–51.
2 Insel, T. R. (2011). Mental Illness Defined as Disruption in Neural Circuits. Retrieved December 26, 2013
3 Insel, T. R. (2006). Testimony to United States House of Representatives Subcommittee on Health of the Committee on Energy and Commerce. Retrieved December 26, 2013, from
4 Insel, T. R. (2009). Translating scientific opportunity into public health impact: A strategic plan for research on mental illness. Archives of General Psychiatry, 66, 128–133.
5 Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33, 846- 861.
6 Whitaker, R. (2010a). Anatomy of an epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Crown.
7 Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). A disease like any other? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry, 167, 1321–1330.
8 Lasalle, J. M., & Yasui, D. H. (2009). Evolving role of MeCP2 in Rett syndrome and autism. Epigenomics, 1, 119–130.
9 American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
10 Insel, T. R. (2013). Transforming diagnosis. Retrieved December 26, 2013
11 Kirk, S. A., Gomory, T., & Cohen, D. (2013). Mad science: Psychiatric coercion, diagnosis, and drugs (pp. 163-209). New Brunswick, New Jersey: Transaction Publishers.
12 Lieberman, J. A. (2013). DSM-5: Caught between mental illness stigma and anti-psychiatry prejudice. Retrieved December 26, 2013
13 Szasz, T. (1961). The myth of mental illness: Foundations of a Theory of Personal Conduct. New York: Harper & Row.
14 National Institute of Mental Health (2013). DSM-5 and RDoC: Shared interests. Retrieved December 26, 2013
15 Insel, T. R. (2007). Neuroscience: Shining Light on Depression. Science, 317, 757–758.
16 Morris, S. E., & Cuthbert, B. N. (2012). Research Domain Criteria: Cognitive Systems, Neural Circuits, and Dimensions of Behavior. Dialogues in Clinical Neuroscience, 14, 29-37.
17 National Institute of Mental Health (2013). NIMH Research Domain Criteria (RDoC). Retrieved December 26, 2013, from NIMH
18 Kupfer, D. J., First, M. B., Regier, D. A. (2002). A research agenda for DSM-V. American Psychiatric Association, Washington, DC.
19 Insel, T. R. (2011). Improving diagnosis through precision medicine. Retrieved December 26, 2013
20 One Mind for Research. Retrieved December 26, 2013
21 Friedman, R. A. (2013). A New Focus on Depression. New York Times. Retrieved December 26, 2013
22 Insel, T. R., & Quirion, R. (n.d.). Psychiatry as a Clinical Neuroscience Discipline. Retrieved December 26, 2013
23 Herper, M. (2013). Why Psychiatry’s Seismic Shift Will Happen Slowly. Forbes. Retrieved December, 2013
24 Peele, S. (1981). Reductionism in the psychology of the eighties: Can biochemistry eliminate addiction, mental illness, and pain? American Psychologist, 36, 807–818
25 Nakamura Heads Peer Review at NIH (2013). APS Observer, 26, 24-27. Retrieved December 26, 2013
26 NIH announces first funding opportunities for the BRAIN initiative. (2013). Retrieved December 26, 2013
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