This has meant a 28% increase in spending for the neuroscience and basic behavioral science division, up from 2% in 2005. That number reflects spending on the BRAIN initiative and on genomics. An additional 25% is spent on translational research, and only 10% – a reduction of about 17% since 2011 – on traditional services research and clinical trials, reflecting a preference for “experimental medicine trials that will be more informative of disease mechanisms,” Dr. Insel wrote. From 2011 to 2014, external spending on clinical trials dropped, from $110.3 million to $75.3 million. Monies spent on services research remained virtually steady at about $67 million annually.
Clinical experience matters
Although Dr. Gordon is celebrated for his neuroscientific work in optogenetics – an emerging technology not yet tested in humans that, if feasible, will allow scientists to turn on or off neurocircuits implicated in a range of mental diseases, including schizophrenia – he has maintained a clinical psychiatric practice for most of his career, whereas Dr. Insel has not.
This is seen by many as a sign Dr. Gordon might be the man to bridge the divide among proponents of less neuroscience and more services or clinical research.
“We trust that Dr. Gordon’s clinical training and exposure to day-to-day challenges of people living with mental illness will impress upon him the need to balance the NIMH’s research portfolio,” said Dr. Lewis-Fernandez, also director of the Hispanic Treatment Program at the New York State Psychiatric Institute.
Having one foot each in clinical practice and bench science might even have enhanced his candidacy for the directorship.
Dr. Francis Collins
“While it is not necessary to have a neuropsychiatry background to be a visionary, Dr. Gordon’s background enables him to have an exceptionally broad vision of the field of mental health that spans cutting-edge science to clinical care,” Dr. Gordon’s new boss, National Institutes of Health director, Francis Collins, MD, PhD, said in an interview..
Firmly stating his commitment to neuroscience’s “tremendous potential” to improve patient care, Dr. Gordon said he believes most clinicians do not struggle to recognize various states of mental illness, but that they do run into fragmented care, which hurts their practice. “The biggest impact [the NIMH] would have during or immediately after my term would be figuring out how to get therapies that we know already work implemented either better or more uniformly.”
He cited as an example, the Recovery After an Initial Schizophrenia Episode (RAISE) program, an early intervention strategy that involves integrated care in an outpatient setting aimed at reducing the duration between first-episode psychosis and treatment. Widely considered an NIMH success story when compared with treatment as usual, both in terms of actual outcome data and patient satisfaction, Dr. Gordon said he believes it demonstrates how the NIMH can help mend fragmentation of mental health services. Using RAISE as a model “can have an impact in relatively targeted spheres,” he said.
Neither such systems engineering, nor Dr. Insel’s “experimental medicine,” should be the NIMH’s primary activity, according to Dr. Pickar. “Early intervention in the outpatient setting is lovely, but it’s not going to help research too terribly much. If you work directly with patients, you will be forced in the right direction,” he said.
As many as 40 patient beds per day were dedicated to clinical observation and treatment of patients with serious mental illness during his tenure, according to Dr. Pickar. In the past year, NIMH patient beds have totaled 24 with an average daily census of 92%, 8 of which are for pediatric-focused research. Often, beds are shared with other institutions such as the National Institute on Alcohol Abuse and Alcoholism, according to an NIMH spokesperson.
The combined reduction in both intra- and extramural clinical research does not bode well for patients, Dr. Pickar said. “Every advance in understanding the biology of serious mental illness starts with the clinical phenomena. That has gotten lost.”
Part of a bigger plan
Decisions over the NIMH’s priorities are not made in a vacuum, however. When asked about what aspects of clinical practice he expects to be the focus during Dr. Gordon’s tenure, Dr. Collins pointed to the presidential directive for precision medicine, saying he believes that eventually mental health diagnoses will “incorporate all of the information coming out of genetics, neuroscience, and behavioral science ... following the model of what is becoming the standard for cancer and heart disease.”
Research into the prevention of comorbid medical disorders in mental illness, and into ketamine as a rapidly acting, novel depression treatment, are important to the NIMH’s short-term focus, Dr. Collins said. But he also stressed that the quality of psychosocial treatments is “another very important area,” as is expanding access to treatment and reducing mental health disparities.