RESEARCH FUNDING IN PSYCHIATRY : HAVE NIMH AND CIHR OVERLOOKED SYSTEMIC BIAS?
- Posted by Editor JPR
- Posted in Editorials & Commentary, Papers
Vol 2 #11
Mona Gupta MD CM, FRCPC, PhD
University of Montreal
The psychiatric research enterprise has grown considerably over the last two generations and the quest to link the clinical manifestations of mental illnesses to underlying pathophysiological mechanisms has dominated the research agenda. By convincing funders that this is the central problem in psychiatry, this quest has also dominated the resources available to support research.
At the same time, there is a relative lack of research interest in the nuts and bolts of clinical interactions. Psychiatrists do a great many things in practice for which there exists very little empirical support. On what basis do we insist that residents learn and practice clinical case formulation? Is empathy really necessary for successful treatment? Does it matter that a psychiatrist pays attention to her feelings in reaction to a patient? Although generations of authors and clinicians have asserted that these and other practices are important, even essential, aspects of the delivery of good psychiatric care, in reality we know little about whether or not they are clinically useful.
In this article, I will argue that existing research funding policies in Canada and the US foster a bias in favour of topics and methods appropriate to validating a disease model of mental illness. This bias leaves many other important questions about psychiatric practice unstudied or understudied. In making this argument, I will examine briefly two examples: 1. Canadian Institutes of Health Research (CIHR) funding of research of mental disorders over the last decade and 2. The National Institute of Mental Health (NIMH) Research Domain Criteria project.
Public Research Funding for Mental Disorders: two examples
1) CIHR Research Funding
The CIHR is Canada’s major public funder of health research. It allocates 1 billion dollars annually towards research at all levels, from students to senior investigators (CIHRa).
The CIHR maintains a searchable database of its funded research projects:
The current database includes applications that date back eight to ten years, and to funding announcements that go back no further than 2007. One can search this database using terms from the CIHR’s list of keywords or one’s own keywords, or both. Keywords include both topic areas as well as broad methodological approaches (e.g. qualitative methods, epidemiology).
I combined the terms ‘mental disorder’ or ‘mental illness’ with ‘societal and cultural dimensions of health’ and ‘qualitative methods’, the two search terms on the official list that could point to studies involving frameworks of understanding, research methods, or scientific questions apart from those lying within the dominant nomothetic quantitative biological paradigm of scientific research. I then repeated this strategy with the two main mental disorders listed on the official keyword list: depression and schizophrenia. I did not restrict my searching by type of funding program (therefore the results include operating grants, salary awards, student awards etc). As Table 1 shows, while there has been considerable investment in research of mental illness, very little extends beyond the medical model of disease.
Table 1: CIHR funding 2007-2016 of all programs in Canadian dollars (number of projects funded in parentheses)
|‘Societal and cultural dimension of health’||‘Qualitative Methods’|
|‘Mental illness’ OR ‘mental disorder’||160, 977, 222 (578)||0||635, 321 (5)|
|‘Depression’||72, 778, 734 (327)
|0||1, 039, 190 (10)|
|‘Schizophrenia’||123, 338, 364 (368)||0||1, 387, 222 (1)|
An exercise of this nature is not without its flaws. For example, the official list of keywords is quite limited, thus, the number of projects related to mental illness, depression or schizophrenia but that adopt approaches or methods that are non-biological or qualitative might be underestimated because these are categorized by investigator-generated keywords that I did not identify. Furthermore, researchers in non-health science disciplines who work in areas of enquiry adopting alternative approaches or topics might be funded through other agencies or have unfunded projects. Nevertheless, we can observe that there is relatively little CIHR-funded research relating to mental illness, depression and schizophrenia that focuses on societal or cultural aspects of illness or uses non-quantitative methods. This may be due to a lack of prioritization of such topics by the funder, lack of applications by researchers, or both.
CIHR allocates approximately one-third of its funding for its designated priority areas while two thirds is oriented towards investigator-initiated themes (CIHRb). Meanwhile, a researcher’s career progress in the non-private sector is often dependent on securing research funding. Researchers who wish to advance in their careers are unlikely to pursue areas of enquiry and submit applications for topic areas where funding is extremely limited. Over time, a growing body of research in more readily funded topic areas can be easily mistaken to indicate that there is more to be discovered or known in that area and unchecked, epistemic biases can become self-sustaining.
2) The Research Domain Criteria project (RDoC)
In 2009, the NIMH released its RDoC project, a framework for studying mental disorders unconstrained by DSM diagnostic categories. The RDoC is a grid which divides mental life into five domains: negative valence systems, positive valence systems, cognitive systems, social processes, and arousal and regulatory systems, each of which can be further broken down into component constructs (for example, negative valence systems include the constructs of fear, anxiety, sustained threat, loss, and frustrative non-reward). These five domains are expressed at eight different levels or units of analysis: genes, molecules, cells, circuits, physiology, behaviours, self-reports, and paradigms.
The NIMH has decided to shift a substantial portion of funding towards those projects which conform to the RDoC model. For example, the overview of the new (September 2016) strategic plan states, ‘For the Institute to pursue its mission of transforming the understanding and treatment of mental illnesses most effectively, we request that all new and competing applications be targeted to the research priority areas within the four Objectives of the Strategic Plan’ (NIMHa).
Under strategic objective 1, we find the following suggestion regarding applications for research funding, ‘NIMH encourages research that seeks to define the neural bases of complex behaviors and mental illnesses….The Institute encourages applications that propose to advance scientific discovery through novel methods and approaches, interdisciplinary scientific collaborations, and integration of multi-dimensional data to discover the complex neurobiological architecture of the processes underlying normal brain function’ (NIMHb).
(The reader is directed to the NIMH website for a detailed list of the strategic objectives, research strategies to achieve each objective, and the research priority areas within each research strategy) (NIMHa).
The RDoC project orients psychiatric research in a certain direction, that is, towards a biological understanding of mental illness. To wit, ‘NIMH recognizes that manifest mental illnesses are likely the late signs of changes in brain circuits and disruptions in behavior and cognition that began years earlier’ (NIMHc). Furthermore, RDoC is structured by the assumption that the best way to understand mental illness is through biology and the best way to intervene is by acting upon the bodies of individuals. The NIMH’s approach to research funding then serves to reinforce these beliefs.
III. Resource allocation ethics for psychiatric research funding?
Research contributes to the way we understand mental illness: what proportion of the expression of mental illness can be accounted for by a problem in an individual’s body versus a problem resulting from his or her social, cultural or other circumstances? Research also contributes to defining what really matters in mental health care: what pill is selected for which diagnosis, versus the nature and quality of the interactions between provider and patient. Because resources for research are limited, privileging certain lines of enquiry necessarily comes at the expense of others (Sadler 2011, 33). Favouring certain topics or methods may be justifiable, but in the interests of fairness and accountability, seems to require an explicit evaluation process that goes beyond scientific review. Thus, how to allocate of resources for research fairly constitutes a problem of research ethics similar to resource allocation within clinical practice. But unlike clinical resource allocation which is a robust subfield of bioethics, existing research ethics frameworks such as the Tri-Council Policy Statement (CIHR, NSERC, and SSHRC) focus almost exclusively on the conduct of research and do not concern themselves with ethical issues related to the context and funding of research resource allocation. However, this does not need to be the case. Funders could commit themselves to fairness in research resource allocation in order to ensure a just distribution of resources and as a safeguard against epistemic favouritism.
Canadian Institutes of Health Research (CIHRa) http://www.cihr-irsc.gc.ca/e/50217.html
Last accessed March 1, 2017
Canadian Institutes of Health Research (CIHRb) http://www.cihr-irsc.gc.ca/e/50218.html
Last accessed October 25, 2017
National Institutes of Mental Health (NIMHa) https://www.nimh.nih.gov/about/strategic-planning-reports/strategic-research-priorities/index.shtml
Last accessed March 1, 2017
National Institutes of Mental Health (NIMHb) https://www.nimh.nih.gov/about/strategic-planning-reports/strategic-research-priorities/srp-objective-1/index.shtml
Last accessed March 1, 2017
National Institutes of Mental Health (NIMHc) https://www.nimh.nih.gov/about/strategic-planning-reports/strategic-research-priorities/srp-objective-2/index.shtml
Last accessed March 1, 2017
Sadler, J.Z. 2011. Psychiatric molecular genetics and the ethics of social promises. Journal of
Bioethical Inquiry 8:27-34. DOI: 10.1007/s11673-010-9273-z. PMCID: PMC3102532.
Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada (CIHR, NSERC and SSHRC), Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, December 2014. http://www.pre.ethics.gc.ca/eng/policy-politique/initiatives/tcps2-eptc2/Default/
Last accessed May 8, 2017
 There were related search terms on the CIHR list including: ‘mental disability’ and ‘mental and behavioural disease’ but these did not yield relevant results (ie ‘mental disability’ pointed to projects relating to developmental delay rather than mental illness. ‘Mental health’ extended well beyond the scope of clinically-relevant problems. I generated the search terms ‘psychiatric disorder’, ‘psychiatric disease’, and ‘mental disease’ which also yielded no relevant results.
 I examined the title of each project cited under depression (327 projects) and schizophrenia (368 projects) and ascertained that the overwhelming majority of this funded research adopted a biological psychiatry framework.
 These results reflect the search term ‘depression’ combined with ‘mental health’ because ‘depression’ by itself yielded numerous results that were unrelated to the psychiatric sense of this word.
 I give these examples to draw distinctions but recognize that these are not dichotomous or mutually exclusive approaches.