Editor's Comment: The Crisis in Clinical Research

Dr. Hartmann's editorial highlights multiple problems faced by clinical research in child psychiatry and, indeed, in clinical research generally.

First, there is a steadily growing decline in clinical research in all branches of medicine, particularly in research conducted by M.D. investigators. One recent review of the number of successfully funded new applicants to the National Institutes of Health (in all fields) indicated that the percentage of M.D.s has dropped by 30% over the recent 3-year period. Our need to recruit young investigators from the available pool of talented medical students and residents is pressing. Once recruited, they must be supported and nurtured. The enormous skills contributed by Ph.D. investigators should not be minimized. Nonetheless, M.D. investigators have much to contribute as well. Having suffered empathetically as they attempt to help people of all ages who are in physical and psychological pain, they bring passion, personal human concern, and innovative insights to the research effort. We need both perspectives—basic and clinical—to solve major medical problems. There is plenty of work for everyone. But we are losing the clinical perspective.

There are many reasons for the decline in clinical investigators—lack of training in research in psychiatric residency programs, the general de-emphasis on research created by the changes in health care funding and economics, the large debt burden carried by many young physicians, the perceived lack of “sexiness” of clinical research as compared with basic research, and the longer training periods needed because of the increased complexities and technical challenges of research. We desperately need leadership within government and within academic medical centers to address these many problems, so that the dwindling pool of clinical investigators will not reach extinction.

Dr. Hartmann also highlights the particular shortage of articles in the Journal in the area of child and adolescent psychiatry. While this may not (or may) be due to the general shortage of clinical investigators in child psychiatry, child and adolescent psychiatry is very much a priority area for the Journal—as it should be for our field as a whole. We can publish only what we receive, however. Approximately 5%–10% of our submissions are in the area of child and adolescent psychiatry. To increase the number of publications, the pool of submissions must increase. To increase the number of quality submissions that will pass stringent peer review (with a 15%–20% acceptance rate overall), the pool of submitters probably must increase. Which brings us “by a commodius vicus of recirculation” (Larry will understand, and the rest of you can ask him) back to the first point.

Finally, Dr. Hartmann laments the narrowness of DSMism and the general sterility that pervades the clinical endeavor when we limit ourselves to purely objective approaches. Your editor agrees wholeheartedly. (Those closest to her know that she sometimes launches into tirades on this topic.) While evidence-based decision making is a core value of medicine, and while DSM has done a valuable service in standardizing diagnostic practices, we as physicians must also devote a part of our time and energy to understanding how our patients feel and think and change subjectively. This is central to our role as doctors—if we are going to help them as healers, and if we are going to develop innovative insights about disease processes to test in research paradigms. Here we need leadership from academic medical centers and national organizations such as the American Board of Psychiatry and Neurology to ensure that our residents learn that there is more to psychiatry than the DSM menu, structured interviews, and standardized questionnaires.

These issues should be at the top of the agenda for all of us in leadership positions.