Thomas Insel Leaves NIMH for Google

Thomas Insel has just left the directorship of NIMH to run psychiatry at Google Life Sciences. What does it mean?

At NIMH, Insel brought in a big new program, Research Domain Criteria (RDoC), to investigate the biological underpinnings of psychiatric illness. This was very progressive: moving the field off the dead center of psychotherapy (where the Freudian hand still lay heavy when Insel took over in 2002), and shifting laterally towards science and away from psychopharmacology, increasingly dominated by drug companies trying to establish profitable new indications for humdrum drugs.

So far, so good.

There were two problems with the new approach at NIMH. One was the lack of a critical understanding of the different illnesses patients might have. This is called nosology (at the classification end) and psychopathology (at the clinical end). To make any progress in basic research in psychiatry you have to possess a reliable classification of diseases. Otherwise, you are investigating garbage.

The problem in psychiatry had been that many of the major diagnoses in the DSM system, the “bible” of psychiatry, were garbage. Major depression, for example, doesn’t exist. The category is very heterogeneous, a mixture of serious (melancholic) depression and non-melancholic nervous illnesses of various kinds.

Any program that sets out to investigate treatments for major depression (as at the drug companies), or the neurochemical basis of major depression (as at many academic centers) will come up with garbage. Remember the principle once current in statistics: GIGO, garbage in, garbage out.

To his credit, Insel recognized that he couldn’t base his new program on the DSM diagnoses, and said so publicly, causing a big upheaval. But he didn’t offer any new nosology to replace the DSM and said, hey, let’s wing it.

But the thing is, in the current literature there is a lot out there on what the real diseases are. It’s not rocket science to bring some of this together and, with the millions of dollars at one’s disposal for research, investigate the biological underpinnings of such recently discussed entities as melancholia (what Bernard Carroll calls Kraepelin’s Disease), catatonia, and hebephrenia. These are the so-called “three ugly stepsisters” of psychiatry. And, in contrast to “major depression,” they all seem to be real, to actually exist in nature.

Well, anyway, Insel never quite got there, and it’s unclear what will happen under the newbie who will now helm NIMH (not yet chosen).

What will be interesting is to see what Insel now launches at Google, with the millions now newly at his disposal, sort of like exchanging a public NIMH for a private one. Anyone wishing to make progress in basic scientific research has got to crack the nosology-psychopathology nut. Until that is sorted out, you can forget research in genetics (where a reliable phenotype is needed), psychopharmacology (where real end targets are needed), or neuroimaging (where you don’t know exactly what you’re looking at until it has a name).

Oh, yeah, and there’s a second problem with Insel: He often doesn’t play well with others. For example, he was the head of the Interagency Autism Coordinating Committee, and I was personally present at a meeting where he literally cut one presenter off at mid-sentence and told her to sit down after she mentioned that ECT might be effective in treating some of the catatonic symptoms of autism. (To her credit, she didn’t sit down and continued her presentation, as some members of this very politically correct gathering sat there with smoke coming out of their ears. Sort of like Carly Fiorina facing down Donald Trump in the recent Republican debate.)

This controlling bent will not play well at Google, and it will be fascinating to see all this, the science and the office politics, rock out.