On The Mental Health Crisis And The RDoC

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The rest of the presentation can be viewed at http://www.slideshare.net/ISBD/the-future-of-diagnosis-in-the-bipolar-spectrum-the-rdoc-view
"The Future of Diagnosis in the Bipolar Spectrum: the RDoC View," by Bruce N. Cuthbert, Director of the RdoC Unit of the National Institute of Mental Health
The rest of the presentation can be viewed at http://www.slideshare.net/ISBD/the-future-of-diagnosis-in-the-bipolar-spectrum-the-rdoc-view

Mental illness is unforgiving; it is also relentless. Qualities that are closely connected to our sense of self—our motivation, cognition and belief, emotions, affect, and somatic awareness—are the first to betray us when we are ill. Few things are more damning, more alienating, and more pernicious than a pathology that burrows into your soul and turns your experience against you.

A quick perusal of the National Institute of Mental Health’s (NIMH) website alone demonstrates evidence of a crisis. In 2014, an estimated 43.6 million adults in the United States—a shocking 18.1 percent—reported experiencing mental illness in the year before their last survey. Almost 10 million of these adults suffer from severe mental illness. Suicide and disability rates are high, not just in the U.S. but also worldwide. The cost in life is staggering. Moreover, the cost in dollars is too. NIMH estimates have claimed that mental illness has cost upwards to $300 billion dollars each year in the United States, although other more recent estimates claim that this figure is closer to $113 billion.

Clearly, with numbers such as these, something is wrong—either in how we conceive of psychopathology or in how we treat it. For starters, however, the crisis might not be as expansive as reported. Statistics regarding the occurrences of mental illness are often inflated by diagnoses given mostly for insurance reimbursement. Nevertheless, even with just a small proportion of these numbers, it is clear that there is a problem.

So how do we address it? What is going wrong? Allen Frances, who headed the DSM-IV task force, has offered some arguments regarding the pitfalls that have resulted in this crisis. In his view, too many resources in research and clinical practice are geared towards the “worried well,” those individuals who experience mental health symptoms but who do not suffer from severe illness. He states that pharmaceutical research is profit-based, and thus decentered from current needs, and that mental health professionals, state governments, and client advocacy groups are similarly self-interested and ignore the needs of the severely ill. And lastly, he posits that brain-based research regarding mental illness, such as the Research Domain Criteria (RDoC), is a negligent gamble. Or, as he articulates in his article, “There is minimal NIMH investment in research that might promote current advances in clinical care, service delivery, and policy making and instead a doubling down on previously failed bets on future breakthroughs via neuroscience, molecular biology, and genetics.”

Frances’ argument has many points of merit. I agree that we need a policy overhaul and more attention paid to severe mental illness. Similarly, I agree that the profit motive needs to be curtailed in medical research and that the self-interest and political myopia of different groups require more checks and balances. However, I cannot help but feel that we are missing the point when projects such as the RDoC are criticized in the manner of Frances or when commentators suggest that what we primarily need is more research into service provision and psychotherapy.

This proposition might seem strange coming from someone who provides psychotherapy. As a clinical social worker, I have seen how much it helps people. I have been in the trenches, so to speak, and thus I also understand the sheer frustration and urgency. I understand the clarion call for more services and better services. We need it; indubitably we do. We need it all and more. However, what we need the most is a way to win the war. And that is why I support the RDoC.

The purpose of the RDoC is to adopt a multidimensional approach to researching psychopathology that incorporates information from different domains such as genomics, biology, neurology, and self-report. The goal is to develop a model of mental disorder that is dimensional and predicated upon a more thorough understanding of human functioning across the entire spectrum. In other words, not only does it aim to understand illness, it similarly aims to better understand the mechanisms or processes involved in our behavior, emotions, and cognitions so that we can acquire a more valid notion of wellness.

For the lay reader, the RDoC is inexpressibly important because it can help us transcend the limitations of antiquated practices. Although pragmatically indispensable at this time, our current system of diagnosis relies upon the Diagnostic Statistical Manual, 5 edition (DSM-5), which is a categorical system with strong theoretical and conceptual ties to its predecessors. The DSM-5 encourages the diagnosis of disorder based upon whether or not an individual presents and/or reports certain signs and symptoms. While relatively reliable, this method of diagnosis is ultimately predicated upon old ideas and categories of illness that go back to ancient Greece or the ideas of famous psychiatrists from past centuries. When we have so much more knowledge and technological capability available to us now our notions should not remain constrained by pre-modern philosophy any longer than is necessary. Accepting a similar state of affairs in traditional medicine is inconceivable.

Additionally, since the DSM-5 is a broad system that relies mostly upon self-report and the grouping of symptoms it can be misleading. For instance, two individuals presenting with the same symptoms and thus warranting the same diagnosis might actually have greatly disparate underlying disease processes, much akin to how individuals with bacterial or viral infections often present with mostly the same symptoms. Such disparate conditions would most likely necessitate different treatments. However, without research in the spirit of the RDoC, knowing this is impossible. This state of affairs is precisely why so many current treatment methods might be largely ineffective.

I encourage all social workers, marriage and family therapists, psychologists, psychiatrists and any other form of treatment provider to not only educate themselves in the concepts of he RDoC but to support it. Additionally, I encourage the public to do the same.

Furthermore, I advocate for this position not because I have served the “worried well,” per Frances’ criticism, but rather because I have served individuals suffering from gravely severe and chronic mental disorders. Some of the obstacles that Frances discussed I have witnessed and experienced from the point of view of the therapist. I worked for an intensive program. My clients experienced persistent and chronic delusion. They heard voices; they were often blunted, catatonic. They were obsessive, disorganized, disgruntled, and pained. Some, unfortunately, were violent. Many often lived on the streets. Medication regimens and therapy consistently failed to even attenuate their symptoms. And even if they did, a gauntlet of social and economic forces made quick work of any stability that they obtained although this was no necessary condition for relapse. For this reason, and others, it seemed like a majority of my clients entered and exited hospitals and institutions just as regularly as I took weekends. Only a small handful experienced recovery in any sense approaching the semblance of its common sense meaning. For all but an even smaller subset, even a modest recovery was only temporary.

Again, we need more services. This is true. However, where they do exist, and where people are receiving treatment and resources, and where we do in fact help people, it honestly still feels like we are shooting water guns into a forest fire. Try to conceive of combatting Alzheimer’s with words, empathy, and support alone, and without advanced research into its etiology or nature. Without scientific breakthroughs we are destined to lose. There are no talk therapies capable of curing disease. No words—as powerful as they might be in other contexts—can heal the development or occurrence of neurological anomaly or accident. And when it comes to severe mental illness there is no denying that this is exactly where the problem indeed lives, regardless even of putative social etiologies where and when they are supposed.

Yes — battles must be won. Individuals must be helped. However, this term, this word “help” is a concept that is robbed and poor in our current atmosphere. The best “help” available is still a far shot from adequacy. If funding is diverted to brain-based research programs so that, one day, there is a possibility that the word can acquire a sense and reference worthy of its use in the context of medical care then I believe that those resources are well spent. Especially when the choice is not mutually exclusive. The RDoC can coexist with policy reforms that revise and expand our current systems of treatment.

Forty years of neuroscience research has not proven fruitless; it has set the foundation for the RDoC. And even if Frances is correct and ‘doubling down’ on this research leads to no breakthrough in the foreseeable future such an investment is still only improbably a waste.

This is the nature of science. Failure and confusion are the antecedents of success — and as frustrating as failure is — and especially amidst the loss of life — we have to remain steadfast.

After all, what is the alternative? More words? As people suffer and die? Now that would be crime and tragedy.

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