A radical direction change at the National Institute of Mental Health (NIMH) has the research world abuzz. NIMH is the major funder of mental health research and has enormous influence over what kind of research does and does not get done. If NIMH takes an interest in phases of the moon, our research journals will soon fill with studies of moon phases. If NIMH decides psychotherapy is low priority, there will be fewer studies of psychotherapy. You can read about NIMH’s new direction in a recent blog by NIMH director Thomas Insel.
One piece of news is that that NIMH just dissed the newly-released DSM-5, and dissed it in a big way. Insel’s post basically says that DSM is useless for understanding mental health problems and that its fundamental premise—that mental health conditions can be classified meaningfully on the basis of overt symptoms—is flat out wrong. NIMH will no longer fund research based on DSM diagnosis.
This is a seismic shift because DSM previously drove research. The starting point for NIMH-funded research was a DSM diagnosis, which is why we have studies on “major depressive disorder,” “generalized anxiety disorder,” and “social phobia,” and studies on manualized treatments specific to these DSM-defined “disorders.” Part of the definition of an “Empirically Supported Therapy” is that it is specific to a DSM-defined disorder.
This DSM-centricity has led to some strange thinking, from my vantage point. For the self-appointed guardians of “science” who decide what does and does not count as an “Empirically Supported Therapy,” it doesn’t matter if study after study shows that a certain kind of therapy alleviates suffering and helps people live freer and more fulfilling lives. If the research subjects aren’t selected on the basis of a specific DSM diagnosis, the research doesn’t count. No matter that most people go to therapy for reasons that don’t fit neatly into DSM categories. (This is one way proponents of “Empirically Supported Therapies” managed to dismiss voluminous research on the benefits of psychodynamic therapies).
If DSM is going to be the foundation for mental health research, it damn well better identify the important phenomena to study, otherwise we are all involved in a collective game of “let’s pretend.” And DSM generally does not direct our attention to the causes of emotional suffering. For example, it leads us to view “depression” as a disease in its own right, and the phenomenon of interest. But depression may be better understood as a nonspecific symptom—the psychic equivalent of fever—of a wide range of underlying difficulties, for example, in attachment, or interpersonal functioning, or in reconciling inner contradictions. If so, DSM steers us away from psychological concepts that could advance understanding and into a dead end.
NIMH Director Insel makes exactly this point, and eloquently. Since he is a medical doctor, he offers a medical rather than psychological example. “Imagine,” he writes, “treating all chest pain as a single syndrome without the advantage of EKG, imaging, and plasma enzymes. In the diagnosis of mental disorders when all we had were subjective complaints (cf. chest pain), a diagnostic system limited to clinical presentation could confer reliability and consistency but not validity.”
Insel is right. When a patient describes chest pain, it is always the beginning, never the end, of an assessment process. No competent doctor would move from “chest pain” to treatment without attempting to understand the cause of the chest pain, which could be anything from indigestion to heart disease to lung cancer. No one would make a naïve statement like, “statins are empirically validated treatment for chest pain,” but we hear comparable statements in psychology and psychiatry all the time (“CBT is empirically validated treatment for depression,” “SSRIs are empirically validated treatment for depression”). When a patient describes depressive symptoms, that too should be the beginning of an assessment process. DSM treats it as the end.
If depression is better understood as a common observable manifestation of a range of underlying difficulties (like fever), then research on DSM-defined “depression” is throwing different people with very different difficulties into the same hopper, averaging them together, and pretending that the differences between people are just random error—mere statistical “noise.” The findings of this kind of research can be nothing but an uninterpretable mish-mosh. (But if the uninterpretable mish-mosh for the treatment group is statistically significantly different from the uninterpretable mish-mosh for the control group, an “Empirically Supported Therapy” is born).
From this vantage point, it is no accident that decades of research on DSM-defined “depression” has failed to show that that any form of treatment is more effective than any other. Research shows that all bona fide treatments are equally good and equally bad. Drugs, CBT, IPT, psychodynamic therapy—they all look pretty much the same when viewed through the lens of DSM-based research. That’s not much to show for decades of research and hundreds of millions of research dollars.
NIMH director Thomas Insel sees all this clearly and aims to put an end to research based on sham diagnostic entities that do not map onto meaningful causes. For him, DSM diagnostic categories are an impediment to good science and should never drive research.
Unfortunately, that’s where the sophisticate thinking ends and the naiveté begins.
Stay tuned for Part 2.
Jonathan Shedler, PhD is a Clinical Associate Professor at the University of Colorado School of Medicine. He lectures to professional audiences nationally and internationally and provides clinical consultation and supervision by videoconference to mental health professionals worldwide.