Julio Licinio, MD, FRANZCP, is Deputy Director for Translational Medicine and Head, Mind and Brain Theme at the South Australian Health and Medical Research Institute and Strategic Professor of Psychiatry, Flinders University School of Medicine in Adelaide, South Australia. He is the current and founding Editor of three Nature Publishing Group journals; Molecular Psychiatry, The Pharmacogenomics Journal and Translational Psychiatry.
Ten years ago I wrote an editorial in Molecular Psychiatry (2004;9:1) entitled “A leadership crisis in American psychiatry.” I commented on the fact that while psychiatric disorders represent some of the most fascinating as well as medically and socially relevant afflictions of mankind, there really was not strong leadership that brought those disorders to the forefront of medicine and medical science where they belong. The case is sadly the same today as a worldwide predicament, not just an American problem.
Mental illness contributes more to the global burden of disease than all cancers combined, and there is a huge discrepancy between the burden of disease and research expenditures in mental health. The US, UK, Canada and Australia spend well under 10% of their medical research budget on mental illness, while these disorders represent close to 20% of each country’s total burden of disease. We have state-of-the-art tools in genetics, imaging and other research modalities to finally tackle these challenges, yet government research expenditure is meager, several drug companies have closed down their in-house mental health research programs and leading academic health science centers have de facto divested from psychiatry, in the context of weak and insufficient leadership in the field. How have we come to this?
First, psychiatry does not make money in the revenue-generating academic health system of the United States. The US leads the world in many areas, including medicine and medical research. And in the US nearly all academic medical personnel is self-funded from research grants – which have become incredibly tough to get – or from clinical services. Academic health science centers, due to their sheer size and complexity have vast overheads, which are taken from any incoming revenue. Psychiatric treatment consists mostly of outpatient visits of low cost which, after discounting overheads, generate insufficient funds to cover specialist salaries and other expenses. Some say that the larger an American academic psychiatric clinic is, the more money it loses. For this reason, key academic medical centers in the US have either completely abolished psychiatric services from the main academic hospital or drastically cut its size to something that is so small as to be purely symbolic. Over time, compliant heads of academic mental health services have been recruited who do not aggressively advocate for increased institutional resources to advance our field.
Second, the cost of bringing a drug to market has skyrocketed and many exceptionally expensive phase 3 clinical trials in psychiatry have failed. Here we have a problem that is addressable but highly complex. In a very appropriate and expected manner, drug development is conducted by pharmaceutical companies that are not in the business of running large clinical trials. Those therefore need to be contracted out. The question is to whom? University clinics typically treat patients with severe mental illness, most of them unquestionably having the diseases in question. However, doing business with such centers represents a bureaucratic obstacle course that can take months if not years before all issues related to intellectual property and human subjects rights are completely addressed. For profit, clinical trial operations are far more expedient and rapidly responsive to industry; however, as they are paid per patient recruited, such operations will enroll subjects barely meeting diagnostic criteria, most of them not suffering from severe mental illness, and who will consequently respond to any intervention, including placebo. By going through the route of commercially run trials with outpatients such as this, drug companies have ended up with multiple failed trials at the cost of billions of dollars. As a result they are now weary of investing in further psychiatric research and development, despite the fact that psychiatric drugs have been major blockbusters and profit generators.
Third, psychiatric patients are seldom able to advocate for research. The nature of psychiatric disorders is such that the functions affected by those conditions are exactly what would be required for people to organize effectively and efficiently towards objective goals. Someone suffering from severe depression or bipolar disorder may not be capable of organizing protest movements, leading manifestations, or conducting effective fund raising and congressional lobbying. Family members are also still affected by stigma. It is more socially acceptable to run a campaign for one’s child who died of brain cancer than for another that died of suicide in the context of a more complex type of brain dysfunction, such as schizophrenia. Despite notable exceptions, such as Connie Lieber and NARSAD, at present mental health charities are far less effective in private philanthropy than their counterparts in cancer and heart disease.
While having suboptimal leadership at the academic, industrial and philanthropic levels, how can contemporary psychiatry jumpstart itself?