A cruel paradox when it comes to mental disorders

I am a great supporter of mental health research but worry that it has lost its sense of proportion and is chasing the wrong priorities.

The really glamorous stuff consumes almost all of the enormous NIMH budget and now has behind it the huge addition of a $650-million private donation aimed at solving the genetics of mental illness.

Neuroscience is an extremely easy sell to Congress and rich philanthropists because it promises so much — that we are on the brink of achieving fundamental breakthroughs in understanding how our genes and brains work (and sometimes don’t work).

But such overpromising ignores the painful lessons of history. The neuroscience and genetic revolutions have been astounding in their technical virtuosity and fascinating in their findings, but to date, they have not helped a single patient. We have learned a great deal in basic science, but nothing at all that translates to better clinical care.

This is not for want of trying. The smartest people using increasingly sophisticated techniques have spent the last 40 years repeatedly reporting seemingly exciting findings suggesting that breakthroughs were on the near horizon. They were wrong. Most findings either don’t replicate at all or turn out to be trivial or are not generalizable.

The horizon for breakthroughs in understanding mental disorders keeps drifting decades further into the future. The more we know, the more we know how little we know. It seems unlikely there will be any grand slam home runs or walks — just singles and lots of strikeouts.

The brain, the genome, and mental disorders are each ridiculously complicated, and their possible interrelationships represent a nightmare of almost endless permutations.

And the latest genetic findings inspire no confidence there will be any quick fix. Hundreds of genes have been implicated as possibly associated with schizophrenia, but each would have only a tiny (if any) effect, and there is also great overlap across different disorders. I doubt that even $650 million will go very far in speeding up the solution of this vast jigsaw puzzle with very small pieces and wonder how much will be wasted trying to go faster than nature allows.

One might argue that it is still worth a vast investment even if the path is long, torturous, risky, and wasteful. After all, our society wastes tons of money on far dumber and less worthy causes (for instance, the excesses of the military-industrial complex, the medical-industrial complex, bank bailouts, etc.).

But there is a cruel paradox when it comes to mental disorders. While we chase the receding holy grail of future basic science breakthrough, we are shamefully neglecting the needs of patients who are suffering right now. On average, it is probably worse being a patient with severe mental illness in the U.S. now than it was 150 years ago. It is certainly much worse being a patient with severe mental illness in the U.S. as compared with most European countries. Access to community care and decent housing is deteriorating; hundreds of thousands of psychiatric patients are homeless or in prison; there is little system in the mental-health system; and almost all research is strictly biological.

I think the welcome infusion of $650 million would have been much better spent to achieve current tangible results (by funding research and model programs to improve the dreary lives of our patients) rather than betting everything on the future long shot that big bucks can dramatically speed up what will doubtless be decades of painstaking and frustrating genetics research.

The neglect of the severely mentally ill is a blight on our society that genetics research will not solve. Its OK to shoot for the stars, but not when we are failing in our day-to-day responsibility. Less glamour, more compassion.


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