Jose de Leon’s Final Comment

Thomas A. Ban: RDoC in Historical Perspective
Redefining Mental Illness by Tanya M. Luhrmann. Samuel Gershon’s question
Collated by Olaf Fjetland

I would like to follow up on this Perspective started by Tom Ban in his essay “The RDoC in historical perspective.”

Since Dr. Sanuel Gershon made the last comment on this perspective on June 4, 2015, I have become aware of Dr. Donald Klein’s articles on the RDoC. I am going, first, to describe Dr. Klein’s first published article; second, to redefine the RDoC as a marketing issue more than a scientific issue; third, to describe Dr. Klein’s second published article; fourth, to describe the answer to Dr. Klein’s second article by Dr. Bruce Cuthbert; fifth, to describe other opinions on the RDoC; and sixth, to give Dr. Klein, who helped convince New York psychiatrists to move from psychoanalysis to psychopharmacology, the much easier job of convincing the current NIMH director to drop the RDoC, for the good of psychiatry, as a specialty.

1) Dr. Klein’s first published article on the RDoC. In December of 2015, Dr. Klein and his collaborators (Weinberger et. al., 2015) wrote as their viewpoint of the RDoC, “It is not based on the science it proclaims and it ignores the key clinical reality of sickness vs wellness.”

2) My view that the RDoC are mainly based on marketing, not on science. My view of the importance of marketing to explain the RDoC can best be understood by looking at history as described by Dr. Ban. I want to remind the reader that 100 years ago Kraepelin (1920) was trying to use the neurosciences of the time to improve psychiatric nosology and wanted to build a research institute so he decided to use marketing, saying, “The foremost task for such a research institute would be to make clear the nature and the sources of mental disturbances, and then to discover ways of preventing them, healing them or making them easier to bear.” If one presents Kraepelin's words to any of the NIMH neuroscientists who defend the RDoC, they are likely to agree that: 1) Kraepelin was not successful in his research program, and 2) Kraepelin’s proposal was not about science, since science in Kraepelin’s day was primitive; rather, it was about marketing.

Then, if one looks at articles by Dr. Thomas Insel, the prior NIMH director who promoted the RDoC, one starts seeing a similar marketing pattern. In 2006, Insel appeared to be competing for funding with other NIH institutes that manage other illnesses and using the same type of marketing that Kraepelin used 100 years ago, “In contrast to researchers in cancer and heart disease who have sought cures and preventions, biological psychiatrists in both academia and industry have set their sights on incremental and marketable advances, such as drugs with fewer adverse effects. This essay argues for approaches that can lead to cures and strategies for prevention of schizophrenia and mood disorders.” The best proof that these words were pure marketing is that five years later it was clear that pharmaceutical companies, who had to respond to their shareholders, decided to abandon psychiatric research (Klein et. al., 2011). Insel insisted on pressing forward by further focusing on marketing and presenting the RDoC as an alternative to the DSM-5, which he considers lacking in “validity” (Insel 2013). In summary, I propose that in 100 years Insel’s statements about curing mental illness and his implementation of the RDoC will seem as laughable as those of Kraepelin may appear to 21^st century neuroscientists.

3) Dr. Klein’s second article on the RDoC. In November of 2016, Dr. Klein wrote a letter titled “RDoC is adverse to scientific creativity” for the Debate section of Acta Psychiatrica Scandinavica. The conclusion of his commentary “emphasizes that RDoC strictures will firmly mold psychiatric research into a particular, at least questionable, model rather than support the necessary creativity for approaching the mysteries of psychiatric illness and treatment.”

In order to compare Dr. Klein with his adversary in the debate (Dr. Cuthbert), any objective observer would have to acknowledge that Dr. Klein is a senior psychiatrist who made very important contributions in the areas of psychopharmacology and psychiatric nosology. On 04/29/17 a PubMed search using the term “klein df” provided 479 articles. The more accurate ResearchGate search using his name “Donald Franklin Klein” provided 641 articles, 24,738 citations and an h-index of 85. More importantly, anybody who knows the history of psychopharmacology knows that in the 1960s Klein was one of the pioneers who fought to introduce the scientific approach in pharmacological trials in a very difficult environment, US academic departments, particularly in his city of New York, which was dominated by psychoanalysts. Fifty years later, due to Klein’s disciples and his disciples’ disciples, there are many top psychopharmacological researchers in New York. It looks worrisome when a senior psychiatrist like Dr. Klein, who is beyond the self-interest of competing for funding or academic honors and who, throughout his career, has demonstrated a major commitment to the best interest of the future of psychiatric research, proposes that “RDoC is adverse to scientific creativity.”

4) Dr. Cuthbert’s answer to Dr. Klein’s second article on RDoC. Dr. Cuthbert is a psychologist working in the NIMH (which anybody objective would acknowledge is a bureaucracy). A PubMed search provided 63 articles when using the term “cuthbert bn” and 91 articles for the term “cuthbert b” (Dr. Cuthbert does not appear to have included his articles in ResearchGate).

As 16 of Dr. Cuthbert’s articles are on the RDoC, it cannot be defended that Dr. Cuthbert is unbiased in his defense of the RDoC since he is one the main developers. In his answer to Dr. Klein (Cuthbert, 2016), he quotes the details of a grant to insist that the RDoC is only one of the main priorities of the NIMH. Dr. Cuthbert finished with a comment, “In sum, the author’s letter misrepresents the role of RDoC in the NIMH’s overall strategic plan and mischaracterizes the particular RFA that is quoted at some length. If anything, the author’s points only serve to point out the extent to which NIMH is attempting to foster scientific creativity with the "RDoC concept.” I recommend that the reader read both comments, but any objective observer would acknowledge that it is worrisome when an unbiased senior psychiatric researcher believes that the RDoC is adverse to scientific creativity. On the other hand, I do not feel particularly comforted by the answer of Dr. Cuthbert that we should believe that the RDoC fosters creativity, when Dr. Cuthbert is a psychologist working in the NIMH bureaucracy who was heavily involved in the development of the RDoC.

5) Other opinions regarding the RDoC. Since 2013, as I have lectured in many countries all over the world from Australia to Argentina, I have heard research psychiatrists express bewilderment because the RDoC approach does not fit with their research in severe mental illness: schizophrenia, bipolar disorder and severe depression. They are concerned that the NIMH, as the leading research center in the US and in the world, is setting an awful example for the future of psychiatric researchers and jeopardizing research in severe mental illness. I always told these troubled psychiatrists that it appears that the RDoC was approved by Insel, but the best sign of how problematic that decision was is that it was not supported by the directors of other closely related institutes, such as NIDA.

If my argument is correct that the RDoC is mainly a marketing strategy and Insel has left the NIMH, one can only wish that the new director of the NIMH, Joshua A. Gordon, M.D., Ph.D., has the good sense to drop the RDoC program, which many psychiatric researchers around the world think is a serious threat to scientific creativity.

References

Cuthbert B. Klein critique. Acta Psychiatrica Scandinavica 2016; 134: 454-455.

Insel TR, Scolnick EM. Cure therapeutics and strategic prevention: raising the bar for mental health research. Molecular Psychiatry 2006; 11: 11–17.

Insel T. Transforming Diagnosis. www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.

Klein D. RDoC is adverse to scientific creativity. Acta Psychiatrica Scandinavica 2016; 134: 452 454.

Klein DF, Glick ID, Shader RI. Central nervous system drug development, basic, and clinical research: thinking outside the box. Journal of Clinical Psychopharmacology 2011; 31: 553-534.

Kraepelin E. The German institute of psychiatric research. Journal of Nervous and Mental Diseases 1920; 51: 505-513.

Weinberger DR, Glick ID, Klein DF. Whither Research Domain Criteria (RDoC)?: the good, the bad, and the ugly. JAMA Psychiatry 2015; 72: 1161-1162.

August 17, 2017