Will RDoC hasten the decline of America's global leadership role in mental health?

Two recent events have substantially increased the perceived global importance of mental health and provide hope that mental health problems will, finally, be allocated the financial and other resources commensurate with their importance to the health of communities. The December 2011 release of the new Global Burden of Disease Study (GBD) results demonstrates the growing importance of mental health problems as a major component of public health in both high-income and low-and middle-income countries (1,2). And in May 2013 the World Health Assembly – the annual World Health Organization (WHO) meeting of ministers of health from around the world – passed a major global mental health initiative, the Mental Health Action Plan 2013–2020 (3).

At this high point for global mental health, the RDoC initiative of the US National Institute for Mental Health (NIMH) unequivocally declares that the traditional basis for identifying mental health problems – ICD and DSM diagnoses – are fundamentally flawed and need to be completely redrawn (4). Despite proclamations to the contrary (5,6), the clear take-home message of the RDoC initiative for the mental health community is that the considerable effort the American Psychiatric Association put into generating the DSM-5 and the effort the WHO is still expending to create the mental health section of the upcoming ICD-11 are misguided and of little use for the promotion of mental health.

If this internecine struggle is taken seriously by the GBD consortium and by ministers of health in leading countries, the NIMH position could make them rethink the rationale for recommending expansion of mental health efforts. The GBD data about mental illnesses are based on epidemiological studies using DSM diagnostic categories, and an important component of the WHO global mental health plan is the Mental Health Gap program (7) which is based on providing treatments for a core group of ICD-defined conditions. If the GBD findings and the proposed WHO interventions are based on flawed constructs, why not wait until the mental health community gets its house in order before reallocating scarce resources to deal with these problems?

The RDoC initiative, though intellectually appealing (to neuroscientists), is tone deaf to the current global trajectory of mental health. The world is clamoring for fixes to the clinical and administrative problems that are limiting the access to care and the quality of care for the vast numbers of individuals with mental health problems (8). This high-profile focus of NIMH funding on the very long-term goal of establishing biologically-based diagnostic categories – which may ultimately prove impossible for a large proportion of the persons we currently treat – will distance NIMH research efforts from the central concerns of clinicians and mental health administrators, particularly those in low-and middle-income countries.

The world will not throw away the current diagnostic system for mental illnesses based on the say-so of the NIMH. There needs to be convincing evidence that any proposed major changes would dramatically improve outcomes. A much better incremental approach would be for the NIMH to emphasize the need to identify dimensional neuroscience measures to help develop more targeted treatments for individuals classified according to current diagnostic systems. This will allow the research to remain relevant to the needs of clinicians and health care systems (which need stable diagnoses to function) and, thus, continue to receive the political support it needs to get sustained funding. Once this approach has generated evidence of its ability to improve treatments by identifying distinct subgroups within current diagnostic categories, NIMH will then be in a much better position to recommend changes in the diagnostic system focused on regrouping conditions that respond to (or can be prevented by) similar interventions.

A diagnostic system is first and foremost a cultural product, a community's attempt to create meaning, to categorize phenomena of interest in ways that facilitate predicting and, possibly, changing future outcomes. Many institutions within a community – ideological, cultural, social, economic, and scientific – participate in the process of classifying and managing health conditions considered departures from “normal”. Scientific research is only one of many stakeholders in this process and it does not operate independently of the other stakeholders; both the outcomes of scientific research about health and the utilization of these outcomes are heavily influenced by the socioeconomic environment in which they arise and are used. The involvement of a wide range of stakeholders in the development of both DSM-5 and ICD-11 is a clear example of this process. In contrast, the RDoC initiative will attempt to develop a diagnostic system with as little input as possible from the non-neuroscientists: the not-so-implicit message is that economic realities, social factors and cultural preferences should wait until the neuroscientists have discovered the “truth” and then fall into line accordingly. This biological reductionist approach is naïve about the role of diagnostic systems in the real world. A diagnostic system must serve the ever-changing needs of all stakeholders. Moreover, these stakeholders need to be integral to the process of developing successive iterations of the diagnostic system, not bystanders.

Will major mental health funders in other countries follow NIMH down the RDoC road? In the past, the economic strength of America and its ability to attract leading specialists from around the world has allowed it to maintain intellectual leadership in many fields, including mental health. But as middle-income countries gradually increase their research funding for mental health and as other high-income countries increase their funding for multinational mental health projects, the proportional contribution of NIMH to global funding for mental health research will inevitably decrease. As this happens, it is likely that the intellectual leadership in global mental health will become increasingly multipolar. At present, it remains unclear how this gradual changing of the guard will affect priorities in global mental health research.

The siren call of biological fixes for biopsychosocial problems has dominated medical research for several decades, so mental health research priorities in other countries may follow the NIMH Pied Piper. But the new emphasis on the public health burden of mental disorders highlighted by the GBD findings and the urgency of the need to resolve these pressing problems highlighted by the WHO Mental Health Plan may induce some countries to disengage from NIMH at the RDoC juncture, and allocate increasing proportions of mental health research funding to the universal problems of expanding the range, quality and utilization of services. If that happens, the inevitable slow decline of American intellectual leadership in global mental health will accelerate.