Insel Outlines the Psychiatry of the Future Treating Disorders of Neural Circuitry

The diagnosis and treatment of mental illness is haunted by four “inconvenient truths.” That’s what NIMH Director Thomas Insel, M.D., told APA members today in his annual meeting lecture “From Psychiatry to Clinical Neuroscience.” Those inconvenient truths are these:

• We have failed to “bend the curve” in the prevalence and the cost of mental illness

• More people are getting more treatment, but outcomes are not getting better. So, more of today’s treatments may not be sufficient to bend the curve.

• We don’t know enough to ensure prevention, recovery, or cure for too many people with serious mental illness.

• We need to transform diagnostics and therapeutics if we are going to make significant progress.

Insel outlined some of the problems that have hindered efforts to bend the curve. These include the fact that diagnosis is limited to observable symptoms, and detection is almost invariably late; etiology of most mental illness is unknown; and prevention is not well developed for most disorders. Treatment is trial and error, and there are no cures and no vaccines.

Moreover, what is known as the mental health “system” is a poorly integrated maze of nonspecific pathways of care, with some people entering through the emergency department, criminal justice system, the primary care system, or nonprofessional services. Diagnosis and treatment vary from provider to provider and from patient to patient.

Knowledge of the brain, despite enormous advances in recent years, is still in its infancy, Insel pointed out. “The brain is a world consisting of a number of unexplored continents and great stretches of unknown territory,” he said.

But Insel also described a promising future in which mental illness is re-envisioned as a disorder of brain circuitry that will be greatly advanced by the president obama’s brain initiative, announced in April 2013.

Research is revealing how chemical imbalances can lead to circuit dysfunction, and in turn to behavioral symptoms, and Insel said the connections that are emerging can be used in the development of diagnostic tests for brain disorders that are today diagnosed late through observation of symptoms. “We can now study the mind with the tools of neuroscience,” he said.

For instance, he presented evidence that is revealing ADHD to be a disorder of delayed cortical maturation. He also presented evidence of schizophrenia as neurodevelopmental disorder with distinct risk and prodromal stages that allow for early intervention.

Finally, he described the NIMH Research Domain Criteria (RDoC) project, which he said will work in tandem with DSM. “DSM/ICD will continue to be the basis of clinical care,” he said. “RDoC is a framework for research in which NIMH will support researchers to deconstruct current diagnostic categories or identify dimensions that extend across categories. RDoC will develop through an information commons that integrates data from many sources, transforming the way we diagnose mental disorders in the future.”