A joint statement to quell the controversy noted how the APA's DSM-5 and the NIMH's Research Domain Criteria project, or RDoC, were “complementary, not competing, frameworks” working to advance mental illness research. But any hopes of calming the situation ended with a May 20 column in the New York Times by Dr. Richard Friedman, professor of clinical psychiatry at Weill Cornell Medical College, who described the NIMH-APA disagreement as a “high-level kerfuffle” and said Insel's post calling for more understanding of the neurobiology of psychiatric disorders was “curiously lacking in historical perspective.”
Friedman, who was unavailable for comment, wrote that the research breakthroughs Insel was seeking were years away and any treatments based on those studies were further away still.
“In the meantime, the millions of Americans with mental illness need treatment now,” Friedman wrote. “They and their psychiatrists don't have the luxury of waiting for definitive scientific knowledge.”
Bruce Cuthbert, director of the NIMH Division of Adult Translational Research and Treatment Development, is coordinating the RDoC project and said the controversy is the result of a misunderstanding. According to Cuthbert, Insel's blog post was not intended for the general public and was aimed at the research community to advise them on the direction the NIMH was headed, which is “a move to more precise medicine” that offers treatment that smaller groups of patients respond to.
Cuthbert cited the cystic fibrosis drug Kalydeco as an example, and noted how it works only for patients with a particular genetic alteration that includes only about 4% of cystic fibrosis patients. He added that cancer treatments are moving in the same direction.
In psychiatry, Cuthbert said, scientific breakthroughs could help specific patients with specific autism disorders. For depression, treatment may specifically target anhedonia, a form of depression typified by patients' inability to enjoy the things they used to.
Cuthbert noted the importance of such goals by explaining that mental disorders can be the most debilitating of illnesses because they strike patients when they're young and can last for life.
“DSM is essential for diagnosis—and the earlier you get treatment, the more effective the treatments are,” he said. “RDoC is a move to find something better—for treatment and prevention.”
Dr. Stephen Strakowski, psychiatry chairman at the University of Cincinnati College of Medicine, agreed.
“My own opinion was DSM-IV was working reasonably well,” Strakowski said. “But, absolutely, there's a huge need to better understand the brain.”
Strakowski's research involves using genetics and medical imaging to identify children at risk of bipolar disorders and develop better treatment and prevention strategies.
“Imaging and genetics are the future of psychiatry,” he said.
At issue is the search for objective methods for diagnosis that can be substitutes for current subjective methods.
One company said it has a way to do both.
CogCubed is a Minneapolis-based provider of video games that track patients' reactions to form a diagnosis.
“My job is to sift out the truth,” said Dr. Monika Heller, chief medical officer at CogCubed and a child and adolescent psychiatrist. “Psychiatry always gets a question mark by others in the medical field because much of what we do is subjective—though I would argue much of what they do is subjective as well.”
Heller said CogCubed is working to create games that “sift out and clarify what's going on” using a mix of objective measures and cognitive behavior observations. Reactions can also be measured and compared before and after medication or behavior therapy.
Kurt Roots, CogCubed founder and CEO, said the games have been described as a “behavior MRI.”
“You're doing the behavior stuff, but doing it in a way that's objective,” he said.
Follow Andis Robeznieks on Twitter: @MHARobeznieks