Out of Balance: National Institute of Mental Health Spending in 2012 and 2020

NIMH Study of Physiology, Treatment, and Psychotherapy

In 2012, the NIMH spent 72% of its budget on studying physiology, i.e. the brain and genetics.  In 2020, that percentage increased to 75%.  Examples of studies include a 2012 study on neuronal signaling pathways during learning and their effects on memory and a 2020 study looking at neuronal cells in mice and human stem cells and their effect on neural circuits (NIMH Project Reporter, 2020, 2012). The purpose of both are to understand potential brain and physiological processes underlying mental illness.

In 2012, the NIMH spent 20% of its money on studying treatment and only seven percent on studying treatment with psychotherapy. In 2020, those percentages fell to 14% and four percent respectively. As a psychotherapist and student of psychotherapy, this is concerning to me. It seems like an imbalance that is unlikely to enable the NIMH to fulfill its mission to “pave the way for the prevention, recovery and cure (of mental illness).”

Implications of NIMH Research Priorities

In its mission statement, the NIMH gives equal weight to “understanding and treatment of mental illnesses” and to “basic and clinical research.” But its research priorities are heavily weighted towards studying the brain and genetics and away from studying treatment and psychotherapy. This research portfolio would suggest there is little evidence of the effectiveness of psychotherapy in treating mental illness. That is not the case. The efficacy of psychotherapy in treating mental illness is supported by strong and plentiful evidence. There have been so many studies establishing its efficacy that we now have meta-analyses of the meta-analyses (Leichsenring et al., 2023; Shedler, 2010). A meta-analysis of studies compared outcomes for depressed subjects who received psychotherapy with those of wait-listed controls found an average effect size of 0.70 compared with an effect size of 0.31 for care-as-usual (i.e., antidepressant medication) and 0.43 for other control groups (Munder et al., 2018).  That effect size far outstrips reported effect sizes for antidepressant therapy (Cipriani et al., 2018; Kirsch, 2009). Additionally, effective psychotherapy need not cost more than medication treatment (Heuzenroeder et al., 2004; Kirsch, 2009).

Studies of psychotherapeutic intervention find that about 80% of patients report significant improvement and the more psychotherapy they receive the more likely they are to report improvement (Cuijpers et al., 2021; McLean, 2022; Wampold, 1997, 2001). And there is no significant difference between the types of psychotherapy people receive. Therapies focused on depth, insight and relationship, such as psychodynamic therapy, Gestalt therapy, humanistic and existential therapy, are just as effective as cognitive-behavioral therapy (Cuijpers, 2023; Olano, 2017; Shedler, 2010). 

What has the NIMH Gained from Studying the Brain and Genetics?

This imbalance might be justifiable if the NIMH were making progress in understanding and treating mental illnesses, but that is not the case. In spite of investing billions of dollars in studying neural circuits, neurotransmitters, neurons, brain chemistry and genetic dynamics, the NIMH has yet to find a meaningful or nuanced relationship between that physiology and the thoughts, emotions, intentions, perceptions and behaviors which human beings experience and use to live their lives (Nour et al., 2022). Neither has the NIMH been able to understand enough to enable the diagnosis of any mental illness through the use of a brain scan, laboratory test or genetic dynamic (Garcia-Gutiérrez et al., 2020; Hahn 2019, 2023; Joseph, 2022; Moncrieff et al., 2022). In the words of Nour and his colleagues (2022): “Despite three decades of intense neuroimaging research, we still lack a neurobiological account for any psychiatric condition. Likewise, functional neuroimaging plays no role in clinical decision making” (p. 2524).

Despite reports that appear regularly in the popular press, no genes for mental illness have been found. The claimed effect sizes for genes associated with “mental illness” are tiny – on the order of one in 100 for depression or attention-deficit hyperactivity disorder (ADHD) and one in 500 or less for schizophrenia (Hahn, 2019). In other words, for every 100 (or 500) individuals that has a specific form of a gene (called an allele), there will be one extra case of the index condition – depression or ADHD or schizophrenia, in this case.

As researchers discover more and more genes said to be associated with an increase in risk for a diagnosis of schizophrenia, the average effect size per gene has decreased. This was expected. What was not expected, however, was that, as the number of “schizophrenia-associated alleles” has soared, the aggregate effect, or the effect of all of them together, has diminished as well (Trubetskoy et al., 2022). This suggests that whatever these researchers are measuring may not have any biological significance.

In reviewing the contribution of the Human Genome Project to understanding the etiology of schizophrenia, psychiatrist E. Fuller Torrey and colleagues (2020) concluded, “three decades later, NIMH’s genetic investment has yielded almost nothing clinically for those affected” (p. 1).

Dr. Thomas Insel, Director of the NIMH from 2002 to 2015 spoke to this failure in 2017. 

I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs – I think $20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.(Rogers, 2017).

What is surprising is that Dr. Insel made that claim in 2017, yet funding of neuroscience and genetics both in real numbers and as a proportion of the NIMH budget has increased since.  Significantly, studies of treatment and psychotherapy received less money in 2020 than in 2012, even though the overall NIMH budget in 2020 was 37% higher than it was in 2012.

Other Problems with the NIMH’s Emphasis on Studying Physiology

There are other problems with this focus of the NIMH on studying the brain, genetics and biochemistry. No matter how many studies find an association between some physiological dynamic and a psychological state of being, mood or behavior, there is no evidence that the physiology caused the psychology. Correlation does not prove causation. If we use the scientific principle of parsimony and looked at other mind-brain dynamics (i.e., laughing, weeping, the stress response, blushing or voluntary movement) to determine the direction of causality, we would assume the opposite: that it is the psychological dynamics that are causing the physiological dynamics (Harrop et al., 1996; Stahl, 2012). Case in point: Jeffery Schwartz and his colleagues performed brain scans of 15 patients diagnosed with obsessive-compulsive disorder. All of the brains were abnormal. Half of the patients were treated with selective serotonin reuptake inhibitors, SSRIs, and the other half received cognitive-behavioral therapy. By the end of the study, all patients had improved. When their brains were scanned again, all had become normal (Schwartz, 1996).

Additionally, human beings use their minds, not their brains, to live their lives. The mind and brain are not the same thing. The brain is an organ of the body. The mind is a vastly powerful, creative and facile faculty that humans use to do everything they do: understand the world; build machines, computers, buildings, bridges; create art; go to the moon; relate with other humans in productive and satisfying ways; develop and manage artificial intelligence. Given the present state of neuroscience, studying the brain is not going to help us understand the mind.  As neuroscientist William Uttal says in his book Mind and Brain: A Critical Appraisal of Cognitive Neuroscience, neuroscientists think they have a theory of how the brain creates the mind. But they aren’t close to having such a theory and it is doubtful they ever will have one (Uttal, 2013). It is unlikely that we will understand and effectively treat the mind through studying the brain or through any kind of materialistic science. But we could understand and treat the mind through the use of phenomenology, the study of human experience in using the mind. The NIMH has done very little of that.

In its effort to understand mental illness, the NIMH is spending most of its money on studying parts of human beings rather than whole human beings. But this may be a situation in which the whole human being is more than the sum of the parts and in which studying the parts will not help us understand the whole. Again, the focus of NIMH on studying physiological parts of human beings is unlikely to contribute much to fulfilling its mission – “(to pave) the way for prevention, recovery and cure (of mental illness).”

The NIMH’s Lack of Interest in Suicide or the Impact of Race, Ethnicity, Sexual Orientation and Gender on Treatment Outcomes

Although there is much interest among clinicians in the impact of race, ethnicity, sexual orientation and gender on treatment outcomes, the NIMH spent very little on studying those factors. In 2021, only five percent of total studies were of a specific ethnicity. In 2020, that rose to 11%.  In 2012, only nine percent of psychotherapy studies looked at the impact of race, ethnicity, sexual orientation or gender on treatment outcomes. In 2020, that fell to four percent.

Amidst concern about rising suicide rates, the NIMH spent only two percent of its funds in 2012 and four percent in 2020 on studying suicide. This lack of spending on suicide and the impact of ethnicity, race, sexual orientation and gender on treatment outcomes represents a disconnect between the concerns of patients, families, clinicians and the general public and the research priorities of the NIMH.

Given the NIMH’s lack of interest in studying psychotherapy, one would think there is nothing left to learn about psychotherapy, but that is not the case. Following are some areas of study that might improve the effectiveness of psychotherapy:

• Which kinds of therapy are most useful with different kinds of people? With different diagnoses?
• Studies of the aspects of the therapeutic relationship to determine which parts of it contribute to effective therapy.
• Qualitative studies of patient experience to determine which interventions and methods of therapy are associated with the best outcomes.
• Studies comparing the effectiveness of therapy provided online or over the phone with therapy provided in person.
• Studies of efforts to expand the accessibility and affordability of psychotherapy.
• Studies of the comparative effectiveness of different kinds of therapy with persons of different racial, cultural, ethnic, sexual and gender identities.
• Studies of efforts to reduce the incidence of relapse.
• Studies of efforts to reduce dropout rates.

In conclusion, the NIMH’s focus on studying physiology in an attempt to understand mental illness, its lack of support for studying treatment and its meager study of treatment with psychotherapy are not likely to enable it to satisfy its goal of “paving the way for prevention, recovery and cure (of mental illness).”

This conclusion begs the question: What, if anything, can be done about this? The NIMH is an agency of the Federal government. It is part of the National Institutes of Health. It receives appropriations from a Congressional committee that reviews its accomplishments and requests for money each year. One thing we can do is share this information and concern with members of that committee and make an effort to testify at hearings on appropriations. Also, the NIMH has an Advisory council comprised of citizens who are interested in mental health. We can share this information with that Council and meet with its members to discuss its implications.  Finally, the NIMH is in the process of hiring an Executive Director. Perhaps we can have some influence over that process. If readers of the Bulletin have other ideas about how to influence the NIMH’s research priorities, I would like to discuss them with you. Please email me here: agalves2003@comcast.net.