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Rethinking funding priorities in mental health research

  • Roberto Lewis-Fernández (a1), Mary Jane Rotheram-Borus (a2), Virginia Trotter Betts (a3), Lisa Greenman (a4), Susan M. Essock (a5), Javier I. Escobar (a6), Deanna Barch (a7), Michael F. Hogan (a8), Patricia A. Areán (a9), Benjamin G. Druss (a10), Ralph J. DiClemente (a10), Thomas H. McGlashan (a11), Dilip V. Jeste (a12), Enola K. Proctor (a13), Pedro Ruiz (a14), A. John Rush (a15), Glorisa J. Canino (a16), Carl C. Bell (a17), Renata Henry (a18) and Portia Iversen (a19)...
Summary

Mental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.

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Copyright
Corresponding author
Roberto Lewis-Fernández, MD, Director, New York State Center of Excellence for Cultural Competence, and Hispanic Treatment Program, at the New York State Psychiatric Institute, Unit 69, Room 3206, 1051 Riverside Drive, New York, NY 10032, USA. Email: rlewis@nyspi.columbia.edu.
Footnotes
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See commentary, pp. 510–511, this issue.

Declaration of interest

Some authors work in research areas (e.g. optimising interventions for people with mental illnesses) that could receive additional funding if the recommendations for realignment of funding priorities made in the article were implemented. Specific conflicts of interest: R.L.-F., National Alliance on Mental Illness, Eli Lilly & Co, American Psychiatric Association, Cambridge University Press, UptoDate and American Psychiatric Publishing Inc.; D.B., Pfizer, Roche, Takeda, Amgen; M.F.H., Otsuka, Education Development Center, Policy Research Associates; A.J.R., Medavante, Takeda, Eli Lilly & Co, Santium Inc.

Footnotes
References
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1 Hoddinott, J, Rosegrant, M, Torero, M (eds). Investments to Reduce Hunger and Undernutrition: Copenhagen Consensus 2012: Solving the World's Challenges. International Food Policy Research Institute of Washington DC, 2012.
2 World Health Organization (WHO). Investigating in Mental Health. WHO, 2003 (http://www.who.int/mental_health/media/investing_mnh.pdf).
3 Murray, CJL, Frenk, J. Ranking 37th-measuring the performance the US health care system. N Engl J Med 2010; 362: 98–9.
4 Society for Neuroscience. Science Funding Resources. Society for Neuroscience, 2015 (http://www.sfn.org/advocacy/neuroscience-funding/worldwide-neuroscience-initiatives).
5 Norris, SMP, Palmer, C, Stroud, C, Altevogt, BM, Forum on Neuroscience and Nervous System Disorders, Board on Health Science Policy, Institute of Medicine. Developing a 21st Century Neuroscience: Workshop Summary. National Academies Press, 2015.
6 Priebe, S, Burns, T, Craig, TK. The future of academic psychiatry may be social. Br J Psychiatry 2013; 202: 319–20.
7 Insel, T. Director's Blog. National Institute of Mental Health, 2014 (http://www.nimh.nih.gov/about/director/2014/best-of-2014.shtml).
8 Ford, ES, Capewell, S. Proportion of the decline in cardiovascular mortality disease due to prevention versus treatment: public versus clinical care. Annu Rev Public Health 2011; 32: 522.
9 World Bank Group. Chapter 5: Early childhood development. In World Development Report 2015: Mind, Society, and Behavior. World Bank, 2015 (http://www.worldbank.org/content/dam/Worldbank/Publications/WDR/WDR%202015/Chapter-5.pdf).
10 National Institutes of Health. The NIH Almanac: National Institute of Mental Health. NIH, 2015 (http://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-mental-health-nimh).
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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Rethinking funding priorities in mental health research

  • Roberto Lewis-Fernández (a1), Mary Jane Rotheram-Borus (a2), Virginia Trotter Betts (a3), Lisa Greenman (a4), Susan M. Essock (a5), Javier I. Escobar (a6), Deanna Barch (a7), Michael F. Hogan (a8), Patricia A. Areán (a9), Benjamin G. Druss (a10), Ralph J. DiClemente (a10), Thomas H. McGlashan (a11), Dilip V. Jeste (a12), Enola K. Proctor (a13), Pedro Ruiz (a14), A. John Rush (a15), Glorisa J. Canino (a16), Carl C. Bell (a17), Renata Henry (a18) and Portia Iversen (a19)...
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eLetters

The Second Enlightenment

Saad F Ghalib, Consultant Old Age Psychiatrist, behavioral sciences pavilion,SKMC,Abu Dhabi,UAE
16 August 2016

For the NIMH members to await the departure of Thomas Insel in order to express their opinion freely as to how research funds should be allocated, is a testament that elitism continues to dominate. Moreover, it symbolizes the fact that what got started during the enlightenment over 300 years ago with a range of ideals centered around liberty, free speech, reason, tolerance, democracy and constitutional government never fully materialized for the average individual. Asking stakeholders and the public to consent (democratizing research) for what is deemed to be more cost-effective strategies in dealing with mental disorders will be fraught with difficulties. There’ll always be those who very skillfully sell their theories or products to the public even when not backed by rigorous scientific evidence. Moreover, historically scientific breakthroughs are more often driven by competition rather than collaboration! In this day and age, individuals, companies and governments will go the extra mile in order to safeguard the intellectual rights of major technological and biological breakthroughs considering the latter’s potential in boosting their relevant countries GDPs.

How can we even contemplate prevention in mental health where in reality, the APA is making a very good job in labeling every conceivable personal or social ill, backed by pharmaceutical industry with variety of medicines to match. I am afraid the public is sold on this and the call of the NIMH is probably too little too late!

It is probably of some consolation to the public that major psychiatric disorders (schizophrenia, BPAD, major depression) are still uncommon. However, what we commonly see in practice are personal, social and work related stressors packaged as disorders. The latter, primarily is a consequence to value systems taking a major battering over the past few decades for several reasons (the list is not exhaustive):

1. The conceptualization of value systems in terms of monetary gain and material acquisitions, accompanied by a widening gap between rich and poor. It is no wonder that so many people are bound to suffer the consequences.

2. The rise of super states in order to police what independent democracies are up to; a down side to this would be the gradual erosion of individual autonomy and an excess of politically correct policies.

3. Governments, paralyzed to deal with social and financial upheavals in their countries, ending up promoting the medicalization of their related aftermath (can’t solve it, medicalize it!). It is sort of cheapish to expect social ills to vanish with a simple prescription of an antidepressant, which in reality works on the same neuronal pathway that is found in much lower species, the likes of mice and sea snails.

4. The misplaced and relentless pursuit of precision in all walks of life even when unwarranted. A quantitative tick-box exercise is nowadays the norm in a variety of services so that managers can brag about their results with precision. History teaches us that seeds of imprecision will always be part of even the most precise of scientific theories. When first introduced, Maxwell’s equations were a precise description of the electromagnetic field; inadvertently though they ended up re-introducing the concept of Ether which subsequently failed experimental verification. Another example is the stunning success of Quantum theory, considered by most the most precise theory ever produced by mankind, when predicting outcomes of measurement, is nevertheless silent as to what the true nature of reality is! A mysterious probability wave that guides the electron can nevertheless have material consequences! One last example is the high precision by which a DNA sequence can be written down; yet the mechanism by which these simple repetitive letters do translate into traits is far from clear. Value systems are imprecise by nature; the latter does not have to be a bad thing. On the contrary, we should cherish imprecision for it being the corner stone of diversity, tolerance and creativity. Furthermore, as practicing psychiatrists we ought to know that often, following guidelines with precision does not lead to the desired results for our patients.

Re-building our patients value system will certainly require time, empathy, empowerment and support. The public expect nothing less.

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Conflict of interest: None Declared

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Evidence-based approaches for rethinking funding priorities

Harold Pincus, Professor and Vice Chair, Department of Psychiatry, Columbia University
23 July 2016

Lewis-Fernandez and colleagues make an important point in calling for a broader “public discussion ofhow to apportion funding resources across mental health research domains.” It is critical, however, that this discussion go beyond expert opinion and be informed by systematic evidence-based analyses targeted to answer key science policy questions.

For example, with regard to the “payback” of different types of research investments, a 2013 study by the RAND Corporation, funded by the Alliance of Mental Health Research Funders,examined mental health and neuroscience research in Canada, the USA and the UK, with a focus on schizophrenia (Wooding, et al, 2013). Two approaches were combined to understand how research conducted 20 years ago is linked to current patient benefits and wider impacts. Investigators traced forward from research projects that were highly cited 20 years ago to follow their outputs and also tracked backward from recent advances to determine the flow of research that led to these advances. Among the results from the study was the finding that, within the 20-year time frame, clinical research had a larger impact on patient care than basic research. In addition, the study supported the contention that scientists who work across disciplinary boundaries conduct research with wider health and social benefits.

The bottom line is that, in order tomake the most efficient and effective use of scarce research resources, mental health research funding organizations need to fully engage with and support the 'science of science' field.

Reference:

Wooding, Steven, Alexandra Pollitt, Sophie Castle-Clarke, Gavin Cochrane, Stephanie Diepeveen, Susan Guthrie, Marcela Horvitz-Lennon, Vincent Larivière, Molly Morgan Jones, Siobhan Ni Chonaill, Claire O'Brien, Stuart S. Olmsted, Dana Schultz, Eleanor Winpenny, Harold Alan Pincus and Jonathan Grant. Mental Health Retrosight: Understanding the returns from research (lessons from schizophrenia): Policy Report. Santa Monica, CA: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR325.html.

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Conflict of interest: Adjunct Staff, RAND Corporation Advisor, Alliance of Mental Health Research Funders

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A welcome call for an increased focus on public mental health

Jenny Edwards CBE, Chief Executive, Mental Health Foundation
07 July 2016

This editorial makes an important and timely point. In the UK we are facing a mental health crisis. In any year, one in four Britons experience mental health problems, with the economic cost to the UK calculated to be over £100 billion each year.

Over the last 50 years, we have taken huge strides in improving standards of public health, education and housing. Yet our mental health, something we all possess, has not improved and if anything is declining. This is not inevitable. We simply haven’t invested the time, money or expertise in understanding and sharing how mental health can be protected.

There are two specific issues that need to be addressed. First, the low level of funding of mental health research, which accounts for only 5.8% of total UK health research spend. This means that we are spending £1,571 for every person affected by cancer compared to less than £10 for every person affected by mental health problems. Secondly, and as highlighted in this editorial, there is an imbalance in how this relatively small amount of money is allocated, with considerably less funding going directly into prevention and public mental health.

The answer is not to redistribute money away from neuro and biomedical research into public mental health, but to ensure that new and increased funding is prioritised towards prevention. We need to invest in and search for solutions based on evidence and practice that work in the real world. We need an approach that understands the neglected determinants of mental health and the need to take public health approaches to gather evidence and deliver solutions that help individuals and communities protect and improve mental health. We need an approach that will bring more immediate results and help improve the lives of millions of people.

Links:

The impact of mental health problems: https://www.mentalhealth.org.uk/publications/fundamental-facts-about-mental-health-2015

UK mental health research funding: https://www.mqmentalhealth.org/research/research-funding-landscape

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Conflict of interest: None Declared

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