One of the most insightful perspectives comes from 1 Boring Old Man, who points out that the NIMH is trying to do the same thing as the DSM-5 all over again by focusing on "biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms" [quote is from the NYTimes article]. Dr. Allen Frances, the Chair of DSM-IV, thinks the new NIMH approach has merit, but he strongly criticized the NIMH for over-promising advances that won't arrive for a very long time, while ignoring the present plight of the chronically mentally ill.
Neuroskeptic likened the controversy to the Protestant Reformation, with the NIMH's RDoC (Protestantism) rising to rival the DSM approach (Catholicism), but in the end they worship the same God (biological psychiatry). This focus on the biological basis of mental illness troubles me, since I think it is terribly limiting. So much of a person's well-being is dependent on relational aspects and influenced by culture and society, as the Child in Mind blog pointed out. According to NIMH's mission statement:
The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. For the Institute to continue fulfilling this vital public health mission, it must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.Though this statement does not explicitly constrain the NIMH to only fund studies looking at the biological aspects of mental illness, the language of "curing" someone obviously reflects a biological perspective. Dr. Insel is a quite a True Believer in the premises behind biological psychiatry, as shown in his TEDxCaltech talk:
“If we waited for the ‘heart attack,’ we would be sacrificing 1.1 million lives every year in this country,” he said. “That is precisely what we do today when we decide that everyone with one of these brain disorders, brain circuit disorders, has a behavior disorder. We wait until the behavior emerges. That’s not early detection, that’s not early prevention.”As ridiculous as the above position sounds to me, let me play devil's advocate and future-think. Suppose the NIMH succeeds beyond anyone's—even Dr. Insel's—wildest dreams. What if their biological paradigm is able to elucidate at the brain circuit level (including all the circuits for positive/negative emotional valence, cognition, social processes, and attention/arousal) exactly what is happening when a person is depressed, or anxious, or hallucinating, and technology advances enough so that treatments can directly target those dysfunctional brain circuits, what then?
Well first, to make the diagnosis, there will have to be some kind of brain imaging examining the circuitry, likely coupled with obtaining a person's genetic profile. Given the complicated wiring in the brain, this will have to be done by a computer instead of a human. Treatments clearly won't be like today's medications that just target a receptor or set of receptors. To target a circuit, I can envision several methods: 1) The circuit would either have to be ablated using precise neurosurgery or interventional neuroradiology; 2) Some kind of medication would be used in conjunction with a device outside the brain that allows the medication to become active only in certain targeted areas of the brain; 3) Some sort of nanotechnology with tiny smart robots inside the brain reprogramming circuits. Because the brain is so plastic and easily influenced by the environment, a person will likely need repeated procedures or continuous treatment to prevent the circuitry from reverting to its previous state. And we haven't even talked about prevention, which seems to be Dr. Insel's goal. To do that, everyone would have to get brain-scanned on a regular basis and genotyped.
Certainly, new technologies will come along that I can't even imagine today. However, none of this will be cheap. Even certain cancer drugs today (which aren't that high-tech in the grand scheme of things) can cost hundreds of thousands of dollars per year. So once those super-expensive new brain treatments come out, who will get them? As we've seen with cancer treatment, rich people like Steve Jobs can get genotype-specific treatments and out-of-state liver transplants that ordinary folks cannot afford. Thus, it's hard for me to envision these advances in understanding brain circuitry doing much, if anything, for "public health."
Even trickier are the ethical issues that these new advances would pose for society. If you can correct the circuits causing a person's cognitive dysfunction and hallucinations, then you can certainly damage them as well. Who would we trust with such technology? Pharma? The government? China already locks up dissidents in mental hospitals; imagine if the Chinese authorities could rewire the circuits contributing to a person's desire to protest injustice. And what would happen if we no longer need any human contact, sunshine, exercise, or purpose in life to ward off depression or anxiety? Would we be content to live like the oblivious human batteries in The Matrix?
Before you accuse me of being a nutty conspiratorialist, consider this: If I were to time travel to the 1960's, and I told people that in 50 years time, everyone would have pocket-sized devices that would combine the functionality of TV, radio, telephone, telegraph, camera, newspapers, magazines, books, and myriad other games and diversions; that no one has to remember anything anymore because they can just ask an entity called "Google"; and that people would stare at this device for hours a day, even during social situations like group dinners, I think they would have put me in a psychiatric hospital.
Obviously, not much of what I am saying is new or original. Many science fiction authors have imagined such a dystopia. You can argue that it's the not the NIMH's job to consider all the potential consequences decades or centuries away, and you may be right. But I will say this: The risks of biological psychiatry are great, with uncertain payoffs. Directing those billions of dollars to address issues like transgenerational poverty, child abuse/neglect, interpersonal violence, and the housing of mentally ill in jails and prisons, while boring, will almost certainly reduce the burden of mental illness and help make our society a better place.