by E. Fuller Torrey

(Posted September 4, 1998 … Issue 37)

In many ways, things have never been better for the National Institute of Mental Health (NIMH). Congress is throwing money at it and its companion institutes in the National Institutes of Health (NIH) at an unprecedented rate. Indeed, if Congress's intentions to double the NIH budget over five years are borne out, NIMH's biggest problem will be to find a basket large enough to catch all the funds. Combined with the daily improvements in neuroscience and its accompanying technology, NIMH appears to be entering the research nirvana Lipid City.

But throwing more money at NIMH will not cover some fundamental flaws that have become increasingly obvious in recent years, but are rarely discussed publicly. It may well be, in fact, that a period of largesse is precisely the right time to make the necessary changes. During times of relative famine, the various NIMH divisions and laboratories are so busy fighting over limited resources that it is impossible to focus on underlying problems.

The most important problem underlying NIMH is defining its mission. In March 1946, when the original congressional hearings that led to the creation of NIMH were held, the legislation was called the National Neuropsychiatric Institute Act, "for the purposes of conducting researches, investigations, experiments, and demonstrations relating to the cause, diagnosis, and treatment of neuropsychiatric disorders." At no time during the original hearings did members of Congress indicate that this new institute was to take primary responsibility for all basic neuroscience research, for basic behavioral research, or for the solution to the nation's sociocultural problems. Its main mission was to focus on severe neuropsychiatric disorders, which were defined by NIMH's National Advisory Mental Health Council in 1993 as schizophrenia, manic-depressive illness, major depression, obsessive-compulsive disorder, and panic disorder. In 1946, individuals with these disorders filled half a million beds in state psychiatric hospitals, and the disorders had caused more than 856,000 men (18 percent of all inductees) to be rejected for military service in World War II.

But NIMH, afflicted by some strange Mediterranean mixture of hubris and chutzpah, immediately set off in all directions instead of following the neuropsychiatric main road it was supposed to. More than 50 years later, NIMH has still not taken the main road, and was last seen wandering lost between the hills of human behavioral problems and the cascade of the intracellular second messenger system, which may or may not have any relevance for any brain disease. Name a human problem - any problem - and NIMH will claim responsibility for its solution; name a brain mechanism - any mechanism - and NIMH will claim it as its own. Meanwhile, severe neuropsychiatric diseases continue to be grossly underresearched. This is to the detriment of more than 5 million Americans afflicted with these diseases, as well as to the detriment of American taxpayers, who in 1994 paid $17.4 billion in federal dollars to cover living maintenance costs alone for individuals with these diseases ($5.6 billion in Supplemental Security Income, $9.6 billion in Social Security Disability Insurance, and $2.2 billion in Veterans Affairs benefits).

NIMH has continued to try to do everybody's job except its own. In 1994, for example, it was supporting research grants that should rightfully have been supported by many other NIH institutes and government agencies. Examples include grants on the neurobiology of diabetes mellitus (National Institute of Diabetes and Digestive and Kidney Diseases), family coping and breast cancer (National Cancer Institute), visual competence in early infancy (National Institute of Child Health and Human Development), Alzheimer's disease caregiver well-being (National Institute on Aging), work experience and mental health (Department of Labor), text comprehension and memory (Department of Education), antisocial behavior (Department of Justice), and mechanism of perception by sonar in bats (National Science Foundation).

For some NIMH research grants, such as one that studied correlates of uncertain parentage in monogamous Eastern bluebirds, it is difficult to understand why the work is being supported at all. It is doubtful that information regarding bluebirds' paternity has any relevance to human problems, especially since bluebirds never pay child support. And it certainly has no relevance to understanding severe neuropsychiatric disorders. Yet NIMH continues going down such research byways year after year, currently wasting approximately one-third of its $750 million budget on such projects. Indeed, NIMH's grandiosity is such that if it were an individual, we would urge a trial of lithium.

Meanwhile, important research problems related to severe neuropsychiatric disorders do not get studied. Even so fundamental a problem as which drug to use for which patient has been almost completely ignored by NIMH, which has inexplicably ceded virtually all research in this area to the pharmaceutical industry. The industry in turn has influenced many psychiatric researchers through research support, trips to Puerto Rico and Hawaii, tickets to sporting events, and honoraria of up to $10,000 per talk at major psychiatric conventions. Many psychiatric researchers have been so compromised by their pharmaceutical-industry-sponsored gifts that the research they report is regarded with extreme skepticism by their peers. Basic questions such as the true roles of the newer antipsychotic, antidepressant, anti-obsessive, anti-anxiety, and mood-stabilizer medications are being answered by eight-page drug ads and what the drug representative tells you as he delivers your free pizza, not by objective research trials.

The more fundamental question regarding NIMH's mission is whether it should continue to exist at all as a separate institute. A Martian research administrator, landing in Bethesda for the first time, would note that NIH has one institute for heart disease, one institute for kidney disease, one institute for cancer, and two institutes for brain diseases. Now that we know that diseases such as schizophrenia and manic-depressive illness are just as much brain diseases as multiple sclerosis and Parkinson's disease, why not merge NIMH and the National Institute of Neurological Diseases and Stroke (NINDS) into a single National Brain Research Institute?

This is not a new idea. As early as 1867, a writer in the Journal of Mental Science noted: "How preposterous it is that one set of men should be engaged in the study of the diseases of the brain and nervous system, and that another set of men should be engaged in the study of diseases of the mind and brain, and yet that no regular intercommunication of thought should take place. The time will come when the existence of such a state of things will hardly be believed to have been possible." [1] Now, 130 years later, maybe the time has come. Thomas Detre and Margaret McDonald of the University of Pittsburgh recently suggested in the Archives of General Psychiatry: "We believe more strongly than ever that the time has come for psychiatry and neurology to become a single discipline." [2]

Until that happens, efforts must be made to get NIMH onto the main road of doing research on the severe neuropsychiatric diseases. Perhaps Congress should send out a search party. It should also make its continuing fiscal support of NIMH dependent upon NIMH doing its primary job.

Send us your comments and ideas for future articles.

Endlinks

Schizophrenia's Most Zealous Foe: Dr. E. Fuller Torrey - article exploring the background of the author, including his history with NIMH. From the February 22, 1998 issue of the New York Times Magazine.

NIMH: Looking to the Future - historical overview and future goals of NIMH, by Steven Hyman, the current director. From the NIMH Web site, which also hosts Facts About NIMH, which broadly describes its objectives, and the very readable Fiscal Year 1999 President's Budget Request for the National Institute of Mental Health, which outlines recent progress at NIMH and research priorities for the coming year.

National Alliance for the Mentally Ill: NAMI Resolution - NAMI advocates refocusing NIMH's priorities.