RDoC is necessary, but very oversold

The past half century has witnessed heroic advances in the basic sciences of brain research, genetics, and molecular biology. But there has also been a surprising and disappointing paradox: none of the exciting scientific findings has had any impact whatever on the everyday practice of clinical psychiatry. Fortunately, we have available effective treatments for most mental disorders, but there have been no real breakthroughs in our understanding of psychopathology and ways of treating it. Why the gaping disconnect between a basic science enterprise that is remarkably dynamic and a clinical practice that is relatively static? In fact, psychiatry is really not that different from the rest of medicine in this regard. All the medical specialties have faced (and so far have largely failed to negotiate) a similar bottleneck in translational research. It turns out to be lots easier to discover the fascinating secrets of bodily functioning than to turn these to any great clinical advantage. And because the brain is so much more complicated than other organs, psychiatry confronts by far the most challenging of all translational leaps. Our three pound brains manage to contain more neurons than there are stars in a galaxy, each connected to a thousand others and firing a thousand times a second, and with hundreds of proteins mediating the busy traffic at 100 trillion synapses. It is amazing that a machine with so many moving parts works as flawlessly as usually it does. By comparison, the breast is the most straightforward of organs, many orders of magnitude simpler than the brain. If, despite decades of intensive research, we are still early days in understanding breast cancer, why be surprised that we haven't yet gotten much of a handle on schizophrenia. When we published DSM-III in 1980, the research future for psychiatry seemed bright and likely to deliver a quick payoff for our patients. We had great hopes that deep understanding and practical solutions would emerge quickly from the happy conjunction of powerful new research tools, generous funding from National Institute of Mental Health (NIMH) and drug companies, and the availability of a reasonably reliable diagnostic system that provided specific targets for study and treatment. Soon enough, the journals were filled with seemingly exciting findings on the genetics of mental illness and were decorated with pretty pictures that purported to show brain malfunctioning in the different mental disorders. NIMH was at the center of the neuroscience enthusiasm, dubbing the 1990s the “decade of the brain” and betting the house on a narrow biological agenda to replace what previously had been a more balanced portfolio of research into not only the basic sciences, but also into treatments and health services. In effect, NIMH turned itself into a “brain institute” rather than an “institute of mental health”. Its efforts have succeeded in producing wonderful science, but have failed in helping patients. The brain has revealed the secrets of psychopathology only in frustratingly small packets, many of which do not replicate and none of which has been powerful enough to generate a diagnostic test or a treatment advance that would actually improve clinical practice. NIMH has grown understandably frustrated by this lack of progress and rightly has decided to switch to the new RDoC research track that is described in Cuthbert's paper (1). Rather than continue to study the hopelessly heterogeneous categories of DSM mental disorders, it will instead focus its attention on much simpler dimensions of mental functioning, hoping that these will yield clearer biological answers. Although the RDoC strategy is sound and necessary, the way it was recently announced to the public was badly muddled – misleading, poorly timed, and damaging to the credibility of both NIMH and the practice of clinical psychiatry. A provocative, widely reported press release came just three weeks before the publication of DSM-5. NIMH explicitly trashed all existing psychiatric diagnosis and instead offered RDoC as a better, biologically based, alternative approach. This unwise over-promising about the future blithely ignored the sobering lessons of the past and the glaring needs of our patients in the present. Lost in the bombast of the NIMH press release was that RDoC has absolutely nothing to offer in the present except an untested research tool. RDoC will almost certainly deliver nothing of practical import within this decade. My guess is that it will consist of a slow, steady slog of tiny steps, more characterized by frustrating blind alleys than by any great leaps forward. Granted that descriptive psychiatry (as embodied in both DSM and ICD) has limited specificity and almost no explanatory power, the fact remains that it is currently the only helpful approach to psychiatric diagnosis and continues to be essential and surprisingly useful in clinical practice. Take “schizophrenia” as an example. Our current construct is clearly a research nightmare: heterogeneous, overlapping with near neighbors, no uniform course or treatment response, and no clear pattern of gene or brain findings. Eventually this final common descriptive pathway – “schizophrenia” – will probably turn out to have hundreds of different causes and will require dozens of different treatments. But for now “schizophrenia” does very much inform clinical practice and RDoC has no replacement for it. Moreover, it is a dangerous myth to assume that patients who meet criteria for “schizophrenia” suffer only from a brain disease. Contextual forces play a large role in the onset of schizophrenia and very often are the most crucial elements in its successful management. A supportive environment, a decent place to live, and therapeutically encouraged engagement with school, work, and social activities are now, and always will be, absolute essentials. NIMH has had its attention so distracted by glorious dreams of a future research revolution that it has completely lost touch with the desperate suffering of schizophrenic patients in the present. It pays no attention to, and takes no responsibility for, the mess that is US mental health care. During the same fifty years that witnessed a basic science research revolution, the US has closed one million psychiatric hospital beds. But having provided too little care and housing in the community, we have been forced to open one million prison beds for psychiatric patients who were arrested for nuisance crimes, preventable had they received adequate community services and housing. These patients are suffering greatly not so much for lack of knowledge on how to care for them, but because of a lack of attention and inadequate resources. Patients with severe psychiatric illnesses are worse off in the United States than in other developed countries and their wholesale imprisonment is a throwback to the barbarity of two centuries ago. Meanwhile, NIMH has sat silently on the sidelines ignoring this shameful transinstitutionalization. It should, but does not, feel a strong responsibility to improve the lives of our patients right now – in all the many concrete ways that are already available to us if only there were adequate funding for them. NIMH should advocate in Congress for patients, not just for its own research budget. And the NIMH research budget should support a balanced portfolio across the entire spectrum – from bench to treatment and from treatment to community services. Gambles on brain research are certainly necessary for a better future, but should not dominate so completely over current need.