In a recently published essay, the NY Times science and mental health writer Benedict Carey discusses the vexing gap between psychiatric research and real life care for people with psychiatric problems. He notes that in spite of large sums of money being invested in drug development and basic science brain research and the seeming progress made in understanding neurobiology, our outcomes in the treatment of mental illness have gotten worse over time. Carey attributes this to two core problems. First, he rightly suggests that the fact that most research directly targeted at treatment is funded by the pharmaceutical industry has a well-known distorting impact on what is and how it is studied. This is certainly true but does not really go far enough. Second, he claims that basic science research is largely controlled by a tight group of “in” scientists-mostly through NIMH and its offshoots-essentially there is not a well enough controlled and reviewed process and this leads to unfocused and often unproductive work. Carey is partly correct in both these claims and I’d like to discuss them a bit and add a few other suggestions that I believe have contributed to the problem he described so well.
The fact that the pharma industry is funding most treatment focused research has been good in the sense that they have great wealth and have profit incentive to find drugs to treat mental health conditions. But is has been terribly unhelpful and counterproductive in multiple other ways that Carey does not really elaborate. Pharma controls both what is studied and what is reported. Often the cut off for claiming drug efficacy is established just at the point that a small effect might have been noted for the active drug and then the drug is declared effective even when benefits are quite small. Negative trials can be suppressed-the company funding the research trial often owns the trial data so that they can simply not publish data that suggest worse efficacy for a drug. As a general rule, drug studies are done on carefully chosen subjects who most often have only the problem being studied and don’t have other conditions (this is most often true of drug trials for medical illnesses as well) and psychiatric trials last for weeks to a few months while most patients take medication for longer periods. The result is that drug trials are often not really as reflective of real-world conditions where patients have multiple overlapping problems and take medication for longer periods. Real world results often are worse than the carefully curated trials and many side effects and problems emerge long after trials are over.
Beyond this, pharma funding distorts treatment research in two other important ways. First, since drug development is extremely expensive, companies have little incentive to take a risk in early-stage drug development which has a high likelihood of leading nowhere and losing investments. The result is the lack of real experimentation or novel drug development and the recycling of older drugs for new indications or development of closely related versions of existing drugs that are different enough to allow a company to get a new patent. The second more systemic problem is that as mental health research is funded-with pharma funding treatment and federal agencies under NIMH funding basic science, there is little funding for psychological, psycho-social treatments or public health interventions which we already know can make substantial differences in the care, outcome and safety of those with mental illnesses but need to be further studied and expanded.
Basic Science
Are NIMH and its offspring (NIDA and NIAAA) spending too much money uselessly? I’m pretty certain that there are quite a few favorites and quite a bit of politics. That said, I don’t believe the amount of money spent by these agencies is overly generous given the scope and impact of mental illness and the amount spent on other health areas. I would also suggest-and here I disagree with Carey- the brain is very complicated to study because we cannot really get into it too well when people are alive, and it does not tell us much when they are not. And while animal kidneys work similarly to human ones, the capacity to use animal models to study human brain activity is very limited. We can’t really know what an animal-even an intelligent one-is thinking, feeling or experiencing. It should not surprise us that it can take many years for basic science to produce clinical benefits-immunotherapy for cancer was imagined 100 years ago but it took many years to figure out how to safely make it work in practice. The fact that we have not translated this research into practice yet dies not necessarily suggest the research was not useful.
Carey also rightly pointed out that much of the difficulty in caring for people with mental illness properly is a problem that is endemic to our health and mental health system-a total lack of coordination and integration of our care system-but I’ve taken this issue up in previous posts.
Finally, what to do? We certainly need to consider a more public driven approach to mental health care and research. Since treatment is driven by free market principles, there is little emphasis or incentive to invest in robust prevention or coordination of efforts. We need a national strategy to coordinate clinical care and research. We would be much better off if pharma companies paid into a research fund that ran through the NIMH but was overseen by a broad array of basic, clinical and public health minded scientists and clinicians. We need to invest in basic science, public health and prevention and broad-minded research around both pharmaceuticals and psychological and psychosocial interventions. A national healthcare plan needs to include and address all these concerns if we are to make any headway in preventing, adequately treating, and improving our care of those who experience mental illnesses. We cannot afford to continue on the path or privatizing and splintering research and clinical care.