The National Institute of Mental Health’s 2020 Strategic Plan outlines priorities in basic science research and clinical trials for psychiatry over the next 5 years, emphasizing where advances are needed in suicide prevention, digital health technology, early diagnosis in psychosis, and much more.
Experts’ reaction to the strategic plan is mixed. Some applaud the NIMH for addressing many essential research priorities and for returning a balance to the focus on basic/translational research and clinical advances. Others would have liked to see a different emphasis on some components of the plan.
Focusing on diversity
A greater weight on research in diverse populations and a renewed focus on studies across the lifespan – including developmental origins of psychiatric illness – are among the novel aspects of the plan.
Dr. Jonathan E. Alpert
“The enhanced attention to recruiting diverse subjects and focusing on diversity in our research is new and very welcome,” Jonathan E. Alpert, MD, PhD, chair of the American Psychiatric Association’s Council on Research, said in an interview.
Addressing the entire lifespan is likewise important, added Dr. Alpert, who holds the Dorothy and Marty Silverman Chair of Psychiatry at the Albert Einstein College of Medicine in New York. “Many of the conditions we treat – whether they are mood disorders or even dementia– might have developmental origins that would be best studied early in life.”
Furthermore, the plan promotes more interdisciplinary collaboration. For example, there are new cross-cutting research themes, including prevention, environmental influences, global health, and more. These are areas where psychiatry needs strengthening, said Stevan M. Weine, MD, director of Global Medicine at the University of Illinois at Chicago, in an interview.
In the era of COVID-19, which will involve ongoing diseases and disasters such as those tied to climate changes and disparities, there will be a need to conduct research and train researchers who are more open to new research questions, said Dr. Weine, also director of the Center for Global Health and professor of psychiatry at the university. It also will be important to partner with researchers from multiple disciplines, he added.
Dr. Igor Galynker
The plan also recognizes novel applications of digital technology. In addition, the plan outlines the promise of “harnessing the power of data,” such as machine learning, to help identify suicide risk factors based on large data, for example. However, Igor Galynker, MD, PhD, predicted that this technology will likely identify factors that “we see again and again,” such as depression, other forms of mental illness, and previous attempt history.
“Machine learning is useful but should not be emphasized” even if it is “technologically sexy and almost seductive,” Dr. Galynker, director of the Suicide Research & Prevention Laboratory at the Icahn School of Medicine at Mount Sinai in New York, said in an interview.
Addressing suicide
The strategic plan places a renewed emphasis on suicide prevention. The report cites a “troubling rise in the national suicide rate.” The authors suggested expanding initial success with brief screening tools in emergency departments to other clinical settings. Furthermore, the report highlights evidence that pairing such screening with low-cost follow-up interventions, such as telephone calls, can reduce the number of suicide attempts the following year.
Widespread screening could help identify people at risk, but it relies on the honesty of self-reporting, Dr. Galynker said, adding that about 75% of people who end their own lives never disclose their plan to anyone. Furthermore, suicide intent can be very short-lived – a crisis lasting as little as 15 minutes for some – reducing the likelihood that routine screening will flag a person in crisis.
“What is missing is an individual approach,” Dr. Galynker said while also endorsing the systemic approach to suicide prevention in the plan. “One thing in the strategic plan I may not agree with is the emphasis on administrative prediction measures ... based on drop-down menus and risk factors, and not on patient stories.” Risk factors are useful for long-term or lifetime risk, but they are not going to predict who will switch to acute suicidal state in the next several days or hours.”
Instead, Dr. Galynker suggested screening people for suicide crisis syndrome, which is “a very defined, characteristic, reproducible, and importantly, treatable,” state.
Covering basic neuroscience
Suicide prevention is just one of seven challenges and opportunities highlighted in the strategic plan. The authors also address research priorities for early treatment of psychosis and for research into mental health equity, HIV/AIDS research, genetics, and neural circuits.
“My overall impression is it’s very positive,” said Dr. Alpert, who is also professor and chair of the psychiatry and behavioral sciences department at Albert Einstein. “It really spans basic and translational neuroscience all the way to health services research and health disparities research. And I think, for many of us, we welcome that. It feels very relevant to the broad span of meaningful psychiatric research.”
Dr. Stevan M. Weine
Dr. Weine agreed. The strategic plan is “very helpful,” he said. “It is comprehensive, broad, and multidisciplinary.”
Promoting four overall goals
The plan seeks to promote the four following goals:
- Define the brain mechanisms underlying complex behaviors.
- Examine mental illness trajectories across the lifespan.
- Strive for prevention and cures.
- Strengthen the public health effects of National Institutes of Health–supported research.
The first goal is “an effort to try to make sense of the underlying biology, and that has to be your foundation point,” Ken Duckworth, MD, chief medical officer at the National Alliance on Mental Illness in Arlington, Va., said in an interview. “The reason we don’t have a lot of new drug discovery is because the fundamentals of biology still need understanding. It’s a long-term goal, so it’s hard,” he added. “Everyone living with someone in their life with an illness wants better ideas now.”
The third goal is likewise challenging, Dr. Duckworth said. “That is optimistic and ... aspirational, but very important and valuable.”
Developing innovative models
Regarding the public health goal, Dr. Duckworth cited one of the objectives, to “Develop innovative service delivery models to dramatically improve the outcomes of mental health services received in diverse communities and populations.” Dr. Duckworth explained, “Trying to solve for the problem in the context of an inadequate workforce that is insufficiently diverse – it just gets to something that I’m not sure would have been a priority in the past.
“That speaks to the awakening we’re having as a society. To address some of these historic and systemic injustices and how research can play into that is really important,” Dr. Duckworth added.
Overall, he saluted the plan and its goals. Dr. Duckworth added, “We gave some feedback that we wanted more emphasis on co-occurring disorders, such as research into people with mental health and addiction [issues] and on premature mortality. I think they took some of that feedback.”
Facing ‘significant challenges’
Dr. Weine added. “It sets a path for scientific advances that are responsive to these problems.”
Dr. Joshua A. Gordon
“The future is bright. Looking forward to the next 5 years and beyond, the new NIMH Strategic Plan for Research aims to build on these advances,” Joshua A. Gordon, MD, PhD, NIMH director, noted in his Director’s Messages blog.
“Nonetheless, we face significant challenges,” he adds. “Studies of the origins of mental illnesses suggest that a combination of causes – genetic, environmental, social, and psychological – act on the brain through a complex web of interactions, resulting in a set of heterogeneous and overlapping illnesses.”
“My hope is that the actual funding of research over the coming years reflects the comprehensive, broad, and multidisciplinary characteristics of this strategic plan,” Dr. Weine said.
The NIMH plans to its post progress for each goal on an ongoing basis on the Strategic Plan website.
Dr. Alpert, Dr. Galynker, Dr. Weine, and Dr. Duckworth had no relevant disclosures.