NIMH Lays Out Five-Year Plan to Defeat Mental Illness

The National Institute of Mental Health (NIMH) wants to focus on transforming the understanding and treatment of mental illnesses. An announcement by NIMH Director Thomas Insel, M.D., on July 29 outlines four overarching objectives that will set the priorities for the institute's investment in the next five years.

One objective is to further uncover the biological causes and mechanisms of mental disorders through research in genetics, neurobiology, behavioral science, and other specialties.

Advances in these areas will integrate understanding of the brain and observed behaviors as well as genetic and environmental factors in various diseases. One of the research goals will be to reconsider the classification of mental disorders based on dimensions of observable behaviors (for example, cognitive impairment in schizophrenia and dementia, psychosis in bipolar disorder and schizophrenia) with direct links to neurobiology. This may lead the current clinical-symptom-based diagnostic criteria to be revised or replaced.

“The strategic plan is driven by the recognition that there are new and outstanding scientific opportunities in mental health research,” Insel told Psychiatric News. “We want to exploit these opportunities and focus on what we believe are the most important objectives—areas that hold the most promise to transform mental health care, including new, effective treatments.”

Another objective calls for getting a longitudinal view of the progression of all mental illnesses and understanding their early development to create prevention and early-intervention strategies. A growing body of evidence suggests that abnormal neurodevelopment early in life may be the key to the pathogenesis of many mental illnesses, even though behavioral symptoms may emerge years or decades later. By charting the complete trajectory of these disorders and describing specific risk factors or triggers, the institute hopes to be able to discover interventions to treat the disorders in early stages or prevent them altogether.

Psychiatric research and practice have traditionally focused on late-stage symptoms of these disorders, that is, behavioral manifestations, Insel pointed out. “We have to get serious about detecting these illnesses in their early stages. For this we need to find reliable biomarkers for predicting the risks or detecting early stages of mental illnesses, like cholesterol levels for heart disease or [prostate-specific antigen] for prostate cancer.”

In addition, NIMH will give priority to research into devising personalized interventions for people with mental illness. Genetic as well as environmental variations, including cultural and family factors, are responsible for partial and unpredictable responses to current therapies. Some may go through many trial-and-error courses of therapy without benefits. For example, NIMH-funded studies have already revealed several genetic variations to account for response to antidepressants in some people and serious adverse effects in others. If clinicians can predict who will respond to what treatment with the least safety risk early on, most patients can get better faster without enduring serious side effects. Achieving this objective requires more personalized studies that do not lump all subjects together.

The fourth objective is to better translate research into public health outcomes, a challenging goal since adopting discoveries is usually slow. To this end, NIMH plans to strengthen its partnership with health care payers, service providers, patients, advocacy groups, professional organizations, and other federal agencies involved in mental health issues, such as the Centers for Medicare and Medicaid Services and Department of Veterans Affairs.

“The central theme of this plan is to shift the way we think about mental illnesses so that we begin to address these as brain diseases, really disorders of brain circuits. That is the transformative message of the strategic plan,” said Insel. “The concept is demonstrated in Parkinson's disease, whose symptoms do not emerge until 80 percent of the cells [in the diseased brain region] are gone. Mental illnesses could be viewed in a similar way, with behavioral symptoms representing a late stage of the disease process.

“The hope is that, if we are able to deliver on the objectives, we will move closer to predictive, preemptive, personalized, and participatory medicine. It's a priority to seek biomarkers to help detect the risks, implement early interventions, and personalize care that involves the patient and family. We do that now in cancer and heart disease, but not in mental health.

An exciting indication of the changes to come is that the word“ cure” was mentioned in the strategic plan. Although it is too early to expect the discovery of a cure for any major mental illness in the next five years, Insel noted, “I think it is important that people in mental health hold themselves to the same ultimate goal as all other areas of medicine—to find a cure.” The plan “raises the bar of expectation in the mental health care community.”

The strategic plan was developed over a one-year period and incorporated input from NIMH staff, outside organizations, and more than 500 individuals in the public.

The NIMH Strategic Plan is posted at<www.nimh.nih.gov/about/strategic-planning-reports>.▪