We need more psychotherapy research to better serve our patients. Psychotherapy of multiple kinds has been established as an effective treatment for a range of disorders, and it is perhaps especially useful in patients with histories of early adversity.1 Because psychotherapy works, our patients will benefit most when we learn which elements of psychotherapy lead to change, and how best to deliver these elements to them. The 2015 Institute of Medicine (IOM) Report on Psychosocial Interventions for Mental and Substance Use Disorders2 specifically called for more research identifying nonspecific (ie, shared) elements of psychotherapy that are most effective in leading to change, regardless of the school of therapy. The IOM call for more research into the therapeutic mechanisms of psychotherapies is welcome news, especially because it does not privilege one school of psychotherapy over another. For example, if exposure and response prevention are found to be essential elements associated with change in the treatment of posttraumatic stress disorder, these strategies may be comparably effective whether such exposure and response prevention involves virtual reality exposure to trauma in cognitive behavioral therapy (CBT) or exposure to trauma within the transference relationship in psychodynamic psychotherapy.
We particularly need research exploring how to bring effective psychotherapies or psychotherapy elements to more patients. A recent example of this kind of research is the study by Connolly Gibbons et al,3 which demonstrated that both CBT and dynamic therapy could be taught to clinicians in community mental health settings, and that neither form of therapy was found to be inferior in treating patients with major depressive disorder.
Late in 2016, the 21st Century Cures Act was signed into law as the last major piece of legislation under President Barack Obama. Among its provisions was an additional $1.5 billion for the National Institute of Mental Health (NIMH) to fund research into mental disorders. The IOM call for more psychotherapy research and the increase in the NIMH budget are good news for those of us committed to offering the best and most robustly researched psychiatric treatments to patients—including psychotherapies. For an NIMH struggling with budget cuts that, after inflation, were essentially funding it at 1999 levels, this new funding is welcome. However, unless the NIMH changes course significantly, few of these or any other NIMH dollars are likely to fund research into treatment methods that are either pharmaceutical or psychotherapeutic.4 What’s going on here?
In an initiative that began with President George H.W. Bush’s “Decade of the Brain” in 1990 and then accelerated with the promise of gains to follow from the decoding of the human genome early in this century, the NIMH has become increasingly focused on translational and basic biological research into brain mechanisms and psychiatric genomics. We have learned from this research that the same brain systems seem to be implicated in most psychiatric disorders, that there are no simple Mendelian genes for mental disorders such as schizophrenia, depression, or bipolar disorder but rather that complex “gene-by-environment” interactions play a critical role in the etiology of mental disorders, and that the same bits of genetic material (single nucleotide polymorphisms or SNPs) are associated with more than 1 mental disorder.1 Recognizing the absence of clear evidence from psychiatric genomics or brain research that supports the familiar clinical diagnostic categories described in DSM-5,5 the NIMH introduced a novel dimensional diagnostic system for research, known as the Research Domain Criteria (RDoC), in the hope of better understanding biomarkers of pathology across disorders. The RDoC matrix includes behavior, systems of emotion, cognition, motivation, social behavior, genes, molecules, and neural circuits. This move beyond the DSM makes sense given the absence of clear links between brain mechanisms or genetic findings and clinically familiar diagnostic categories, but RDoC is heavily tilted toward a search for biomarkers—a search some have likened to that for the Holy Grail—with little opportunity provided in the RDoC matrix at this time for the role of relationships and attachment as manifestations of environmental influence within gene-by-environment interactions.
Research linked to RDoC may well lead to improved patient care decades down the road, but it is unlikely to have much impact on the treatment of actual patients in the near term. Although we have improved our understanding of the brain and its mechanisms, developed wonderful imaging capabilities, and greatly increased our awareness of psychiatric genomics, the unfortunate truth is that results from study of the brain and of psychiatric genomics have fallen far short of what was anticipated. For example, in 1999, a genetic revolution throughout medicine was expected to emerge from the Human Genome Project, but this has not occurred.6 At that time, Collins7 described 6 major themes expected to follow from decoding the human genome: (1) common diseases will be explained largely by a few DNA variants with strong associations to disease; (2) this knowledge will lead to improved diagnosis; (3) such knowledge will also drive preventive medicine; (4) pharmacogenomics will improve therapeutic decision making; (5) gene therapy will treat multiple diseases; and (6) a substantial increase in novel targets for drug development and therapy will ensue. Although some small-scale advances like these have occurred in the rest of medicine, in psychiatry the promise has fallen far short. Nevertheless, the NIMH has doubled down in its commitment to study the brain and genes. Under immediate past director Tom Insel, the NIMH shifted ever more of its limited funding toward brain and gene research, with a 25% decrease in funding for the kind of randomized controlled trials we use to test the efficacy of elements of psychotherapy or the effect of drugs. Although the NIMH web site states openness to funding psychotherapy research as part of psychosocial research, the required linkage of grant applications to some biomarker through the RDoC, to the NIMH strategic goals, and to required “experimental therapeutics” severely narrows the scope of possible grant applications. I often see communications from established psychotherapy researchers indicating their dismay about this NIMH stance.
In 2015, working with American Psychiatric Association (APA) Assembly colleagues and 2 established psychotherapy researchers, John Markowitz and Barbara Milrod, we drafted and the Assembly passed an action paper calling on the APA to study the implications of the limited funding for psychotherapy research. Psychopharmacology researchers, who also felt concerned about whether they would be able to conduct future NIMH-funded randomized trials of new medications, fairly quickly joined this effort. Of course, for psychopharmacology researchers, unlike psychotherapy researchers, there are other sources of funding—although we have long since learned that pharma-funded research is an undesirable solution in terms of the development of new drugs.
As requested in the action paper, the APA completed a review documenting the decline in overall NIMH funding, joining the call for more research into treatment methods, while recommending a “both/and” funding stance that recognized the merits of basic biological research as well as research into methods of clinical treatment, including psychotherapy.8
The NIMH move in the apparent direction of an “either/or” (ie, “yes to brain and gene research but no to clinical methods research”) versus a “both/and” approach to research funding is short sighted. A field that was firmly grounded in a biopsychosocial model 40 years ago has now shifted to a biomedical model for the provision of psychiatric care as well as NIMH research funding. It is our patients who are left to suffer, while clinging to hope that the promised big breakthrough of brain and gene research is just around the corner, when it is still likely decades away. A “both/and” NIMH funding approach would of course continue brain and genomic research as a long-term research strategy, but would also reinstate significant funding to study clinical treatment methods—including nonspecific elements of psychotherapy that are associated with change. This is the kind of research that can actually improve patient care and patient outcomes in the near term—research like the study by Connolly Gibbons et al3 mentioned above showing that both CBT and dynamic therapy for depression could be taught to therapists and used to treat patients in short-term community mental health settings. Interestingly, this study was not funded by the NIMH, but by the Agency for Healthcare Research and Quality. The Agency for Healthcare Research and Quality was for a time interested in mental health research, but its emphasis has now shifted to primary care, so that a study like this would no longer be funded today.
In their aptly titled Viewpoint article, “What happens when underperforming big ideas in research become entrenched?” published in the Journal of the American Medical Association in October 2016, Joyner et al6 note that the biomedical brain and genomics focused “big idea” has become entrenched throughout medicine and psychiatry, whereas results flowing from this model so far are disappointing. They go so far as to recommend periodic reassessment of such “big idea” models:
When claims about high-profile, dominant “big ideas” are viewed against their mediocre benefits, it seems that 2 basic courses of action are available. The first is to continue with calls for more funding, more complex measurements, and more sophisticated instrumentation. The second is to reevaluate and reset the current focus. (p. 1356)
They then call for periodic independent reviews of these “big ideas” as a way to accomplish this kind of reappraisal, noting that the assessors doing these reviews:
(M)ust be objective, independent of the funding source, and have no professional stake in whether a particular line of research is deemphasized. The deliverable criterion should include public health benefit achieved by these initiatives (ie, measurable reductions in mortality and morbidity). Criteria such as number of publications, citations, prizes, and recognition are irrelevant as these are simply self-rewarding artifacts of the system. After several decades of substantial investment, the fundamental question is whether these big ideas have improved quality of life and life expectancy, by how much, for how many, and for whom. These are public dollars that should benefit the many, not the few. Mechanisms should be in place to sunset underperforming initiatives. (p. 1356)
Joyner and colleagues raise difficult but important questions. Raising them is appropriate given the potential for unwitting blind spots within the NIMH and the low likelihood that funded researchers or academic medical centers garnering the lion’s share of NIMH funding can serve as adequate checks and balances to such blind spots. The shared commitment of these entities to the “big idea” of brain and genome research may have unintended consequences. One unintended consequence of the either/or research agenda focused on brain and genomic science rather than a both/and agenda that also includes research into treatment methods—especially psychotherapy—is the virtual end of funding of psychotherapy research, which has no realistic alternative funding source beyond government agencies like the NIMH. Another unintended consequence of the either/or stance that follows the de facto defunding of psychotherapy research is depriving patients of near-term benefits that could come from research into treatment methods—even without a link to biomarkers.
Josh Gordon, the new director of the NIMH, has indicated his intention to spend his first year in the role learning the system he is charged with directing. We can only hope that after that period of learning, he will have the wisdom to move toward a both/and NIMH research agenda that certainly continues brain and genomics research with the potential for long-term benefit, while also returning resources to fund research into clinical methods, like psychotherapy, that can have a large impact on real patients in the near term.
Psychiatrists interesting in joining the American Psychiatric Association (APA) Psychotherapy Caucus may send an email to Eric.Plakun@austenriggs.net asking to join. If you will be at the APA annual meeting in San Diego, join us at the meeting of the Psychotherapy Caucus on Tuesday, May 23, 2017, 9:00-11:00 AM Pacific Time. We will meet at the Marriott Marquis San Diego Marina, in the Coronado Room, on Level 4.
The author thanks the following individuals for their help and consultation for this column: Paul Crits-Cristoph, Andrew Gerber, Falk Leichsenring, and Barbara Milrod.