BIRDS ARE EVERYWHERE AT THE National Institute of Mental Health (NIMH). There are sparrows, finches, canaries, bluebirds, parrots, doves, and even rare bowerbirds--all the subjects of research studies. And, of course, there are pigeons. The Institute has 14 research grants on pigeons alone. There are so many birds at NIMH that St. Francis is rumored to be on the short list for NIMH's next appointed director.
NIMH is supposed to be the federal government's pre-eminent medical research institution, investigating the cause and better treatment of serious mental illnesses such as schizophrenia and bipolar disorder, which are expensive, debilitating diseases. But the birds are partial evidence the Institute has run afoul of its basic mission.
The 14 research awards to study pigeons, which together total over $1.2 million per year, were all given to psychologists who propose to learn how pigeons think. In one of them, for example, pigeons are shown a series of pictures to see whether they can recognize the same object differently represented. According to NIMH, this will tell us "how pigeons extract categorical information from photographs of real objects and learn abstract relations." The next time you toss the remnants of your sandwich to our feathered friends in your local park, you will no longer have to wonder what the pigeons are thinking. Just call NIMH and someone will tell you.
Altogether NIMH is currently supporting 33 research grants to study birds. These can be seen on the Internet by going to www.nih.gov, clicking on the CRISP database under "Grants and Funding Opportunities, then typing in "pigeon" or "songbird" under search terms. If, on the other hand, you wish to know how many research grants NIMH is supporting to study bipolar disorder (manic-depressive illness), type in "bipolar." The query will yield a total of 128 hits, but many of these have little or nothing to do with bipolar disorder. Only 14 of them--the same number of research grants given for studying pigeons--are related to testing medications for improving the treatment of this illness. By NIMH's own figures, bipolar disorder affects "more than 2.3 million Americans ages 18 and over" or "about 1 percent of the population," and many of these are in need of better medications for treatment.
Given this meager allocation for research resources for the treatment of bipolar disorder, how does NIMH justify its avian inclinations? Studies of pigeons are said to help us understand cognitive processes and learning. For example, according to NIMH, the research grant described above, in which pigeons are shown a series of pictures, "will increase our understanding of higher-order human cognition, contribute to the detection and development of treatments of cognitive disorders, and facilitate ecologically valid educational practices."
A newcomer to Washington might naively think that facilitating "ecologically valid educational practices" is the responsibility of the Department of Education. But that is not how Washington works. Success in Washington comes from constantly enlarging one's institutional boundaries, and nobody has done this more successfully than NIMH.
Among NIMH's recent research awards are projects that should have been assigned to the Department of Education ("Understanding Reading Problems in At-Risk Children"), the Department of State ("Coping with Change in Czechoslovakia"), the Department of Justice ("Models of Face Recognition"), and the National Transportation Safety Board ("Software System for Prediction of Shiftwork Alertness"). Even within the National Institutes of Health, NIMH assumes responsibility for research projects that clearly belong to other institutes. Recently funded examples include "Ruminative Style Effects on Delay in Breast Cancer," "Mental Health and Lung Transplantation," "Self Regulation and Susceptibility to Colds and Flu," and "At-Risk Irritable Infants."
In reviewing NIMH's research portfolio, it is difficult to find any subject area that NIMH has neglected. Even the arts are represented by research grants such as "Perception and Production of Expressive Microstructure," a project which, for $210,472, studies "the expressive microstructure of music--the systematic variations in timing, dynamics, and articulation that make performed music expressive and aesthetically appealing" NIMH's portfolio is so broad that it qualifies as having delusions of grandeur. Indeed, if NIMH presented itself as a patient, it would be immediately started on lithium.
NIMH's grandiosity is the heart of the problem, for amidst its dabbling in everyone else's work, it has forgotten to do its own. A 1999 study by the National Alliance for the Mentally Ill of NIMH's 1997 research grants ("A Mission Forgotten: The Failure of the National Institute of Mental Health To Do Sufficient Research in Severe Mental Illnesses") reported that only 8 percent of its total grant funds were allocated for research on clinical or treatment aspects of schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder, and panic disorder combined. In 1997, NIMH spent more money on AIDS research, which is the primary responsibility of the National Institute of Allergy and Infectious Diseases, than it spent on schizophrenia research.
A follow-up study by the Treatment Advocacy Center of research grants funded by NIMH in 1999 (available on www.psychlaws.org/nimhreport/index.htm) reported no improvement over the 1997 allocation. The number of research grants that targeted clinical or treatment aspects of severe mental illnesses remained at 8 percent. Only eight new grants were related to clinical or treatment aspects of panic disorder, the same number of new grants that studied songbirds, and only four new grants were related to clinical or treatment aspects of obsessive-compulsive disorder, the same number of new grants that studied fish. It was not supposed to be like this.
Straying From The Park
When NIMH was officially signed into existence by President Truman on July 3,1946, its principal purpose was to support research on severe psychiatric disorders. At the House and Senate hearings that led to its birth, testimony focused on the overcrowding of state psychiatric hospitals and on the large number of men who had not been able to serve in World War II because of severe psychiatric illnesses.
Surgeon General Thomas Parran pointed out that "half of all hospital beds in the country, some 600,000, are occupied by mental patients" and "125,000 new cases of mental disease are admitted annually." Maj. Gen. Lewis Hershey, director of the Selective Service System, provided detailed testimony about the 18 percent of men who had been rejected for induction because of severe mental illnesses and the additional 14 percent who had been rejected because of mental deficiency; thus, one-third of America's potential fighting force was ineligible because of medical problems affecting their brains.
The original bill that led to the creation of NIMH was even entitled the "National Neuropsychiatric Institute Act," emphasizing its medical mandate. And during the hearings several speakers cautioned that this new addition to the National Institutes of Health should focus its resources on psychiatric illnesses, not on "personal problems?' In her testimony, Ms. Lee Steiner, for example, strongly urged NIMH to focus on "psychiatric disorders" rather than problems such as "unhappiness over maladjustments in work, the problems of love and courtship ... The psychiatrist is not the specialist here. Even the best-trained psychiatrists do not necessarily have an internship in the problems of normal living"
NIMH, however, had much grander plans than merely confining itself to severe psychiatric disorders. The psychiatric architects of NIMH had all been trained in Freudian theory and believed that there was a continuum between mental health and mental illness. Dr. Robert Felix, the first director of NIMH, was trained as a psychoanalyst and claimed that "prevention of mental illness implies ... the provision of a climate in which each citizen has optimum opportunities for sustained creative and responsible participation in the life of the community and for the development of his own particular potentialities."
Dr. Stanley Yolles, the second director of NIMH, stated that psychiatrists had the responsibility "to improve the lives of the people by bettering their physical environment, their educational and cultural opportunities, and other social and environmental conditions." And Dr. Bertram Brown, the third director, urged psychiatrists to think of themselves as community "caretakers" and to be involved in such activities as "city planning" "It is more than fantasy," said Brown, "to conceive that one form of assistance to a mayor may be a psychiatrist, since this has already happened in New Orleans."
By the late 1960s, NIMH was involved in activities such as city planning. Dr. Leonard Duhl, a high-ranking NIMH official, claimed in 1968 that the role of mental health professionals should be as a "change agent in society," with the goal of helping "construct a social system that produces mentally healthy individuals." By the 1970s, NIMH-funded Community Mental Health Centers (CMHCs) were involved in many community projects. In Los Angeles, for example, a CMHC organized parents to get a traffic light installed near a school. In Philadelphia, a CMHC board included "resolv[ing] the underlying causes of mental health problems such as unequal distribution of opportunity, income, and benefits of technical progress" as part of its mission statement. And in Chicago, a CMHC board hired Saul Alinsky, a well-known social activist, to advise them on how to promote mental health.
These actions were applauded by NIMH as being part of its grand vision. Today schizophrenia, tomorrow the world! In retrospect the vision was more grandiose than grand and has continued to be so to the present. It is this grandiosity that explains why, even as the research world has moved to molecular neuroscience, NIMH continues to fund research projects such as "Sentence Processing in Japanese and English" ($68,208), "Peer Rejection of Girls" ($505,862), and "Adolescent Romantic Relationships and Their Development" ($200,693).
Out On The Streets
During the 1970s and 1980s, as CMHCs helped with city planning and traffic lights, the state psychiatric hospitals were being emptied in an attempt to deinstitutionalize, or move the mentally ill into less restrictive settings in the community.
In 1955, there were over 559,000 severely mentally ill individuals in these hospitals; today there are less than 60,000. Based on the nation's population increase between 1955 and 2000, if there were the same number of patients per capita in those hospitals today as there was in 1955, there would be over 946,000 patients. That there are fewer than 60,000 means that almost 900,000 individuals are living in the community today who would have been hospitalized a half-century ago.
Where are these people? Half of them are living with their families or on their own and doing reasonably well. The other half, however, are not. Approximately 150,000 of them are living on the streets or in shelters, where they make up one-third of the homeless population. More than 200,000 of them are in jails or prisons, according to Department of Justice studies, often incarcerated for crimes committed because of their severe psychiatric illnesses. Another group died prematurely because of illness-related accidents or suicides. Still others have been moved to nursing homes.
Although NIMH vehemently denies it, there is a direct connection between its failure to focus resources on severe psychiatric disorders and the failure of deinstitutionalization. The sad fate of homeless mentally ill individuals, 28 percent of whom utilize garbage cans for some of their food supply, or of incarcerated mentally ill individuals, is inextricably bound to NIMH's failure to do research on the causes of, and to develop better treatments for, these diseases. The continuing failure of NIMH to do the job for which it was originally created is, in fact, one of the greatest, although least known, scandals in contemporary American society.
On economic grounds as well, the failure of NIMH to do research on severe psychiatric disorders is inexplicable. A 1997 survey reported that the federal government was spending $20.6 billion on federal Medicaid, Medicare, VA psychiatric services, and other federal service programs related to mental illnesses, not including substance abuse. In addition, in 1999, individuals with "mental disorders other than mental retardation" accounted for 31.4 percent of the federal Supplemental Security Income (SSI) payments and 26.6 percent of Social Security Disability Income (SSDI) payments, the largest disease category for both types of payments. In 1999, these payments totaled $19.6 billion. Therefore, the total amount of federal funds spent upon individuals with severe psychiatric disorders is over $40 billion per year. This is three times the annual cost of the nation's space program, four times the cost of all our foreign aid programs, and more than 10 times the cost of the federal prison service. And this, of course, does not include state, county, or city expenditures for these individuals.
What can be said about a government agency that is mandated to deal with a problem that costs the federal government over $40 billion per year and yet is spending minimal amounts to correct it? Even a modest improvement in treatment would produce potential savings of billions of dollars. One might say that the government agency exhibits the kind of illogical thinking seen in individuals with severe psychiatric disorders.
The contrast between what NIMH is funding and what it should be funding is startling. On February 18, 2001, The Washington Post "Style" section carried a feature article about a University of Virginia psychologist who is studying student's feelings as they break up in romantic relationships. "A Date with Heartbreak: U-Va Researcher Studies Dumpers and Dumpees for Science's Sake," it was headlined. And yes, the research was being carried out on a three-year research award from NIMH. Other NIH institutes aspire to get the results of their research published in Science or the New England Journal of Medicine; NIMH settles for the "Style" section of The Washington Post.
Because research budgets are finite, allocating funds to study romantic relationships means that other research proposals do not get funded. Among research applications rejected for funding by NIMH in recent years were proposals to study serotonin receptor genes in schizophrenia, a new drug to treat schizophrenia, the state of dysphoric mania in bipolar disorder, and the cost-effectiveness of second-generation antipsychotic drugs compared to first-generation antipsychotics. None of these proposals were apparently considered to be as valuable as the proposal to study romantic relationships.
The current director of NIMH is Dr. Steven E. Hyman, a respected and well-meaning neuroscientist. In response to increasing criticism of the institute's research portfolio, Hyman has publicly acknowledged that there are research projects he is "not pleased to be funding." Hyman has implemented contracts totaling $20 million per year for drug trials for the treatment of schizophrenia, bipolar disorder, and depression; and he has proudly pointed to these as evidence that NIMH is correcting its past problems. These contracts are certainly a small step in the right direction, but they account for less than 2 percent of NIMH's billion-dollar budget. Hyman has performed a face lift when what is needed is a heart transplant. (Hyman was out of the country and unavailable for comment.)
NIMH also defends itself by citing the possible knowledge of basic brain functions to be gained from research on pigeons and songbirds. Such research is, of course, not without potential benefits. One of the songbird projects, for example, reported interesting findings regarding the regeneration of neurons. This may or may not have any relevance for any psychiatric disorder, but such basic, open-ended research should logically be funded by the National Science Foundation, and not by an institute whose focus is supposed to be on brain diseases. Defenders of pigeon research also sound at times like those who argue that if you put enough monkeys in front of enough typewriters, one of them will eventually compose a Shakespearean sonnet.
NIMH's final defense of its research portfolio is the ultimate fallback for all Washington agencies: Congress ordered us to do it. In fact, as everyone who has lived in Washington for more than two hours is aware, congressional mandates are almost invariably the product of behind-the-scenes negotiations between the agency and congressional staffers. In this case, Dr. Patrick H. DeLeon has played a major role in orchestrating the congressional mandates. DeLeon, a psychologist, is both the immediate past president of the American Psychological Association and a key staffer for Sen. Daniel Inouye (D-Hawaii), who sits on the Senate Committee on Appropriations, which oversees NIMH's budget.
Correcting the problems of NIMH and getting it back to its original mission of researching serious psychiatric disorders will be a formidable task. The combination of inertia and vested interests impedes change in all government agencies. The grandiosity of NIMH is deeply embedded in its culture, and career employees know that they can outlast Dr. Hyman or any other director who takes control for a few years.
Furthermore, NIMH is viewed by research psychologists as an employment program. The more pigeon research grants are made available, the easier it becomes to climb the psychology academic ladder to tenure. The Washington lobbying group for the research psychologists is the American Psychological Society. Its executive director is Dr. Alan Kraut, one of Dr. Hyman's strongest defenders. Coincidentally, Dr. Kraut's wife, Jane Steinberg, works directly under Dr. Hyman as NIMH's acting Associate Director for Special Projects.
The key to bringing about real change at NIMH is implementation of the 1998 recommendations of the Institute of Medicine's Committee on the NIH Research Priority-Setting Process. That committee recommended that "in setting priorities, NIH should strengthen its analysis and use of health data, such as burdens and costs of diseases, and of data on the impact of research on the health of the public" If the "burden and costs of disease" were truly considered, the $40 billion per year in federal costs for severe psychiatric disorders would demand much greater consideration than studies of pigeon thought processes or romantic relationships between college students.
But don't look for such changes any time soon. NIMH is likely to continue along its present oscine course, as it has for the past four decades. Individuals with severe mental illnesses will continue to be the losers. And NIMH's $1 billion dollar budget will continue to buy a lot of birdseed.
DR. E. FULLER TORREY is president of the Treatment Advocacy Center in Arlington, Va., and is also Executive Director of the Stanley Foundation Research Programs.
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|Title Annotation:||questionable research priorities at National Institute of Mental Health|
|Author:||TORREY, E. FULLER|
|Article Type:||Statistical Data Included|
|Date:||May 1, 2001|
|Next Article:||The Washington Monthly Journalism Award.|