Science in the Service of Furthering Mental Health - Dr. Joshua Gordon, Director of the National Institute of Mental Health

Shiv Gaglani: Hi, I'm Shiv Gaglani, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and health care. Today we're honored to do that with one of the nation's top health care leaders, Dr. Joshua Gordon, who is the director of the National Institute of Mental Health. In that role, he oversees an extensive portfolio of basic and clinical research that seeks to transform the understanding and treatment of mental illnesses, paving the way for prevention, recovery and cure. 

I'm looking forward to learning more about the NIMH, which is celebrating its 75th anniversary and getting his views on how to meet the growing need for mental health treatment, including among providers themselves, the promise of psychedelic-assisted therapy and other issues.

So, Dr. Gordon, thanks for taking the time to be with us today.

Dr. Joshua Gordon: Thank you for having me.

Shiv:  So, as you know, many of our audience members are interested in or are pursuing careers in medicine and psychiatry, mental health. Would love to hear in your own words more about your background. What got you interested in medicine and then a career in psychiatry?

Dr. Gordon: I got interested in medicine really through the science. First and foremost, I got interested in biological science, molecular biology, all the cool stuff that was happening in the late 70s, early 80s in that area. That convinced me to major in biology as an undergraduate. I did research with an MD there who had a unique lab that, on the one hand, looked at the molecular biology of neuroblastoma, childhood cancer, and on the other hand, provided almost

a service as an academic lab to clinicians who were caring for kids with this tumor because he could -- with the molecular information he could get in these early days before sequencing tumors was normal -- he could make predictions about the course of illness. This is Dr. Garrett Brodeur at Washington University where I was an undergraduate. 

That convinced me that looking at both biology and pathology could satisfy my scientific curiosity and also lead to a better world for people, novel therapies. In medical school, I got really interested in neuroscience and also simultaneously really interested in mental illnesses, which I think to a certain extent still remain the biggest mysteries in medicine. That's why I chose to go into psychiatry. I also found the practice of psychiatry incredibly compelling because you had the opportunity to really deeply get to know your patients and also you had the ability, with the powerful treatments that we have, to help them dramatically. It was natural for me to continue doing both. Research was always at the fore though.

Shiv: Did you go into medical school expecting to do a PhD? Maybe we can talk a little bit about your PhD because I know a lot of our audience are debating what joint degree to do, if any, or some of them are in MD-PhD programs. Tell us about the original research that you focused on.

Dr. Gordon: I did choose to pursue the combined degree right off the bat. My initial angle there was to continue the work that I'd done as an undergraduate and study molecular oncology. In the first year of medical school the neuroscience course, which was a combination of neurophysiology, and neuroanatomy, really blew my mind. It was just quite intriguing and engaging. That plus a little bit of foray into the latest research at the time, which was about using micro-stimulation to prove that the brain actually was the seat of perception, that

got me very excited about neuroscience and I made the switch. 

My own PhD was in visual cortical plasticity. In those studies, I was able to marry my previous love of molecular biology with my emerging love of neuroscience because this is a time where sophisticated mouse models were starting to be made. This is when knockouts were just coming on board and were just begun to be studied from a neuroscience perspective. I was able to take advantage of those developments and begin study of systems neuroscience in mice with a focus on the development of the visual system. Later on, I would take that in my postdoc and then faculty period to focus on functions of the brain more relevant to psychiatric illness. 

It was really just a combination of being in the right place at the right time that married my past and future interests together.

Shiv: Yeah, that serendipity is a theme that comes up on these podcasts quite often. Interesting about your PhD...my undergraduate thesis was in neuroscience. I was looking at BXD mice, looking at their neocortical volumes, and figuring out what genes were correlated with the size of neocortices in mice. So, I didn't realize some similarities there. 

I was reading one of your interviews on the NIMH website celebrating the 75th anniversary, and I think you mentioned that the idea of leading NIMH came from maybe your PhD advisor encouraging you to apply. Maybe you can talk a bit about how you jumped to the NIMH, but also about the role of mentors because a lot of our learners are interested in finding mentors and cultivating those relationships, and it's cool to know that you've kept in touch with yours for several decades.

Dr. Gordon: Yeah. My career started out like many in academic medicine. As an assistant professor, I had a role in the residency. I had a practice and I spent most of my time doing research. Had a very active lab. It was a wonderful time, really a wonderful fifteen years of my life. I made a number of contributions to the field that allowed me the opportunity to meet lots and lots of people from all over the world and I just was really enjoying being a faculty member.

I was at Columbia University in the Department of Psychiatry there at the time. 

When my predecessor stepped down, I was at the Society for Neuroscience meeting and my PhD mentor, Michael Stryker -- who was an amazing mentor -- he came up to me and he said,

“Josh, you should think about this job.” And why did he come up to me and say that? First and foremost, he knew me well. I had done all kinds of service things when I was in graduate school. I was serving on some university committees. I worked in the schools in San Francisco, teaching neuroscience to middle schoolers. I taught Sunday school at my synagogue. He knew that about me and he knew that I cared about serving the community.

He also knew that I had broad interest in science, that I wasn't only focused on my own research, but I enjoyed delving into other areas of neuroscience more broadly, of psychiatry more broadly. I'm the type of student and faculty member who was always at every grand rounds and seminar regardless of the topic. It didn't have to be in my area. He knew that about me as well. 

So, the fact that Michael had really taken the time to get to know me and thought about me in that context -- this is a job, Josh, that you would love - that's what got me thinking about it.

Shiv: That's fantastic. I'm sure you've mentored some students along the way or some trainees and you yourself were mentored. Do you have any advice on being a good mentor or staying in touch and finding a mentor like yours?

Dr. Gordon: I think both from the mentee and mentor perspective, I'm going to fall back on advice that I got in graduate school which is that a mentor -- no matter how much they care about the mentee's career -- they care about their own career more. Both the mentee and the mentor need to recognize that fact. You have to find a mentor who, number one, cares enough about mentoring that they care about your career, that they want to see you succeed. And also find a mentor who knows and understands that it is in their own best interests to be a good mentor. 

So, I've strived to meld those two things into one in my own interactions with my mentees, that is, to try to think about their careers, to try to think about what they really want to get out of their experience in my laboratory or their interaction. If we're talking about if they're not in my lab, but I'm giving them advice in some other area, try to think about their interests and then also try to recognize that my investment in them will pay off for me so that that desire to be altruistic and that desire to be successful can be seen as two things that are working together as opposed to in opposition.

Shiv: Yeah, I love that advice. I think that applies not only to those kind of relationships, but really any relationship between organizations, between people, as first understanding the incentives -- understanding kind of what the other's goals are -- and second, aligning them. Like how do we find the shared ground? So, that's great advice. 

Dr. Gordon: One hundred percent.

Shiv: Now going to your role at the NIMH, I would love to hear more about how the last several years have gone for you, especially with the COVID pandemic. Can you give our audience an overview of what the size and scope of the NIMH is and what are some of the things you've been working on that you're most excited about? 

Dr. Gordon: The NIMH is the principal funding agency responsible for supporting and conducting mental health-relevant research in the United States and the largest such agency in the world. Our annual budget is somewhere north of $2 billion, about 80 percent of which goes out the door to investigators at universities and other institutions around the globe. 

Our main role is in trying to make sure that good science is conducted in the service of furthering public mental health. That's one answer to your question. 

It's not just dollars, though, it's people. We have about a thousand people who work at NIMH, a good 600 of which are in the intramural research program. They're scientists, technicians, animal care technologists, janitors...the whole works trying to do what any good academic department of psychiatry does: a broad range of mental health relevant research, very strongly focused on neuroscience and translation into treatment. 

Then there's another 400 or so employees whose job it is to ensure that we support the

best research around the globe and particularly in the United States. So, that's program officers who are working with applicants to help them make sure they know what we're looking for and how to go through the process; that's grants management specialists who make all the checklists, make sure all the rules are followed, get the grants out the door; that's HR and travel and all the administrative things we need to have happen; and yes, that is also janitors cleaning floors and administrative assistants making sure that appointments are booked. So, it's the whole range.

One of the things that I love about being at NIMH is that every single one of those people, whether they're a scientist or whether they're a travel specialist arranging my trip to the University of Iowa, they are all committed to the mission. I learned that on my very first day when someone walked into my office and said, “Welcome. You know, I empty your wastebaskets at night and I just want to let you know how excited I am to work here at NIMH, where I know that I'm contributing to something that's going to help people with mental illness.” It's wonderful to work for an organization like that.

Shiv: That's fantastic. It reminds me of that famous story about JFK visiting one of the NASA facilities in the 1960s and asking, I believe, a custodian what they do at the center. And I think the custodian responded, “Mr. President, I'm here to put a man on the moon.” It's great to have that amount of alignment of mission and people and culture. 

So, you've been directing the NIMH for several years now, stewarding it through the COVID pandemic and I know that the COVID pandemic -- along with other trends like social media --

have all exacerbated what we believe to be the mental health crisis. I think a recent CNN and Kaiser Family Foundation survey indicated that about 90 percent of U.S. adults believe that we're facing a mental health crisis. I would love to hear in your own words about some of the biggest challenges and opportunities that you think we see in this moment to address that mental health crisis. 

Dr. Gordon: First, I want to zero in on one of the words you use, which is exacerbated, right? A lot of people are under the impression that COVID caused a mental health crisis. But most of us, including regular ordinary people on the street, know that that crisis was there before the pandemic and the pandemic exacerbated it. And, of course, it exacerbated it not equally for everybody. More affected were the people who were more affected by the pandemic: children and adolescents who missed time in school and time with their friends and in important junctures of development; people on the front lines, which includes, yes, first responders and doctors and nurses and other and folks who work in the hospital in supportive roles, but also grocery workers and taxi drivers and train drivers, et cetera, who couldn't work from home. So, it was an important exacerbation that also exacerbated existing mental health disparities as well. 

One of the biggest challenges, of course, is the sheer size and scope of the burden of mental illnesses that existed before the pandemic and that worsened after. It's most noticeable for children and adolescents. Already, we had a real undersupply of child and adolescent psychiatrists and other mental health professionals -- psychologists, social workers -- whose focus was on kids. That has only worsened as some have left the profession and the demand has increased in the wake of the pandemic so that we hear routinely of children waiting not even days, but weeks for a hospital bed for an acute psychiatric emergency or months for an available appointment from a child psychiatrist. So, these are real challenges for the field. There are opportunities, though, in several different areas.

Number one is just the awareness -- in the general public, amongst care providers and importantly, amongst policymakers -- that mental illness is important, that it's in a crisis mode, that we need to do something. That's led to influxes in dollars being spent even at the federal level on mental health care through the Substance Abuse and Mental Health Services Administration and a greater awareness and interest in working with NIMH to ensure that our research is answering the questions that are most needed to be answered to help kids and others who've been affected not only by the pandemic, but by other influences that have led to

this crisis we're experiencing. 

Another opportunity, I would say, is the confluence of this crisis with tremendous explosion of interest and ability to deliver care through alternative means, which includes digital technologies, includes remote care delivery, and it includes peer support and peer care delivery. You know, the 988 Crisis Line is one example of the latter, where now we have a greatly expanded ability for people to reach out for help in a crisis. We need to back that up with the professional apparatus on the other end. 

So, there's a lot of opportunities that are arising, not just because of awareness, but also because of what's going on in other sectors of society that could have the potential to help us reach more people.

Shiv: Yeah, absolutely. I agree with a lot of those things and some of those themes have come up on the podcast. You know, the reason we call it the Raise the Line podcast is we launched the first episode in April 2020, right when the pandemic was beginning and everyone was talking about ‘flattening the curve’ which is very important, obviously. In the COVID perspective, it was physical distancing, wearing masks, and ultimately getting vaccinated so that we don't overwhelm the health care system with the number of people who have COVID. But that could also be applied to PTSD, depression, anxiety, et cetera. ‘Raising the line’ was the other half of the equation, which is how do we strengthen the health care system? How do we apply telemedicine so we can have one clinician seeing many more patients? How do we get more clinicians trained? How do we retain those clinicians? 

So, one of the elements I think in the challenges we're all facing is there aren't enough doctors in general but also psychiatrists, psychologists, social workers. There's a shortage. But then also the retention of these clinicians seems to be at an all-time low at least based on reports of people who want to leave the profession because it's so demanding. As a clinician and researcher yourself who runs NIMH, I'm curious, what are your thoughts on the staffing of these jobs? How do we train more? How do we keep them in the profession longer? And then, we love getting a little personal wherever possible. What are some of the things you did personally to maintain your own mental health as you went through the training and stayed in the profession as long as you have?

Dr. Gordon: Well, let me answer the latter first. I mean, what drove me to stay in the profession was my engagement around what I love to do. That was, again, predominantly research, but also for the practice that I held, the ability to care for patients without a lot of bureaucracy and really spend my time with the patient. Compared to what most sort of managed care practices would do, I spent a lot of time with the patients. My minimum time was a half hour and more typically forty-five minutes for patient visits. And so to be able to practice the way I wanted to practice was the way that I stayed with it. That's one thing that I know resonates with a lot of care providers, regardless of the care of the kind of care they're providing. 

I think another thing that drove me is this feeling of efficacy. I am not saying that every patient I treated got well. That's just never going to happen in any branch of medicine and certainly not in psychiatry. But I felt like I had a role to play in helping my patients and that most of them responded to the treatments that I was offering and that was tremendously gratifying. If we can increase individuals’ efficacy by ensuring that they are trained in evidence-based approaches, that we continue to make new treatments available to help those who aren't responding to the old ones, if we continue to make it easier to people to use evidence-based approaches, that's, I think one way we can do that.

The researcher’s role in that context is to not just develop those treatments and show that they can work, but also study how best to implement them. How do we make it easy for a health care system, for a practice, for a clinic to adopt these evidence-based approaches? NIMH conducts a lot of research in that implementation side to make it easier for the practitioners. 

The other thing we need to do in mental health specifically to try to resolve the shortage -- to ‘raise the line’, I love that Shiv -- is ensure parity, true parity for mental health. In my own practice in New York, I'm somewhat ashamed to say it, I didn't take insurance. I would negotiate with each patient on their ability to pay, but I didn't want to deal with the bureaucracy and I didn't need to deal with the bureaucracy. One of the reasons I didn't need to deal with the bureaucracy is reimbursement was so low that there were very, very few of us who could afford to take insurance patients even if we wanted to and so there were very few psychiatrists who took it. So, patients were forced to go out of network. That's a situation which continues and it's a big problem in many areas. It's not even that there aren't enough psychiatrists, there aren't enough psychiatrists who take the common insurances, so even a middle-class patient with good health care coverage still has a hard time finding a psychiatrist, and that's also true for psychologists and social workers. 

So, if we can ensure that an hour of a psychiatrist’s time is reimbursed like an hour of physician's time; an hour of a psychologist's time is reimbursed according to the benefit that they're giving the patient and not according to some formula that discounts their professional training or the techniques that they're using...I think that would be really important. We have parity laws on the books, but as the President has recently acknowledged, they haven't actually led to true parity in availability, and that needs to be fixed.

Shiv: I'm really glad you mentioned that because I think when we think about federal research funding, it's often on the very biological aspects of the research -- which are very important -- 

but the other challenge is getting it actually into the hands of patients, into the clinic treatment rooms. 

Just yesterday I was on a call with some contacts and colleagues at the Office of the Surgeon General. Dr. Murthy's been doing a lot talking about social isolation and the fact that this epidemic of loneliness, which he calls it, is the equivalent to smoking for decades in terms of the negative effects it has across mental health, cardiovascular, etc. I would just love to hear about, since I mentioned that, any collaborations you have on social isolation, because that seems to be a major contributing factor to the mental health issues we're seeing.

Dr. Gordon: So, first of all, the Surgeon General has been fantastic to work with. Since day one, when he was appointed, his emphasis has been on mental wellness as much as anything else, in fact, more than anything else. The fact that he's put out report after report after report highlighting mental health as the major challenge of our time has been remarkable, and we've been working with him on each and every one of those reports. Our subject matter experts have had a role to play. It's really been a wonderful collaboration that I really appreciate.

On the loneliness front, we actually have several different research projects that we've funded in that area. One big focus for us has been the effect of loneliness in the elderly and understanding that impact both on their mental health and other forms of health in those

individuals has been a recent focus of our geriatric psychiatry research program. That's actually been done in collaboration with the National Institute on Aging, which has been a great partner in a range of different programs.

So, yeah, we have a lot going on in that area and I hope that in a few years we can have real practical solutions that can make an impact on loneliness and on the mental health effects of loneliness. 

There's another thing you brought up in there that I just wanted to comment on. You pointed out that loneliness has many different effects on the body, including raising risk for mental illness, but also raising risk for other illnesses. I would say that that's true of most, if not all, social determinants of mental health. Whether we're talking about poverty, food security, housing security, availability of parks, availability of nature, discrimination and more....we know all these things play an important role. They all are risk factors for illnesses in multiple organ systems, including the brain.

So, at NIH, we've formed a program funded by the Common Fund, which is an NIH director-administrated pot of money to fund intervention research performed in communities by community organizations -- not universities, but the community organizations themselves -- aimed at improving health across a wide variety of health outcomes and focused on structural determinants of health in those communities like some of the things that I just mentioned. We recognize that through collaboration, we can address these important social determinants of mental health and other forms of health in a more effective way.

Shiv: That's fantastic. That's really, really great to hear that you guys are engaging community members, because having trained at Hopkins partially, there's often this hierarchy in medicine of, you know, MDs over certain physician extenders and then academic labs versus community research. So, it's great to hear that you guys are doing that as well.

Dr. Gordon: Well, you know, the Bloomberg School of Public Health at Hopkins is really one of the leaders in terms of community-engaged research in mental health and other forms of health. So, you have some shining examples there, too, of engaging community members, even in a hierarchical place like that.

Shiv: Sounds good. So, I want to switch to one of the most promising interventions coming up in psychiatry, which has gained a lot of popularity over the last few years. I heard you speak at the Psychedelic Science Conference in June, and then you published a wonderful viewpoint in JAMA Psychiatry called Psychedelics as Therapeutics, Potential and Challenges in July of this year. We're interviewing you on September 14th, which is actually an interesting day because the Multidisciplinary Association for Psychedelic Studies (MAPS) just published its latest study in Nature Medicine. We had the founder of MAPS, Rick Doblin on the podcast previously. And just to say what Nature shared, it says that the “results of a second trial involving 104 further individuals with PTSD and published today were similar to those of the original in which 71 percent of people who received MDMA alongside therapy lost their PTSD diagnosis, compared with 48 percent of those who received a placebo therapy. The drug seemed to work just as well in people who had other mental illnesses, such as depression, and in those who'd had PTSD for a long time. It also seemed to work equally well across racial and ethnic groups.” 

So, obviously, we're all very excited about the promise of psychedelic therapy for

a range of mental health conditions. We'd just love to hear kind of how you got interested in that space, and what your thoughts are right now about both the opportunities as well as the challenges. I know in Australia, they just approved it as a treatment in June. I think there's potential FDA approval of MDMA and maybe psilocybin coming up in the next year or two is what's predicted. So, yeah, we'd just love to hear directly from you about how you got interested in the space and what you see moving forward.

Dr. Gordon: First of all, it's really the provocative results which have gotten me to look at psychedelics in a more concerted way. These new results from MAPS are really wonderful, or I should say potentially wonderful, and there'll be a potential. I'll explain why I say potentially in just a bit. 

So, this is the second of two studies that are setting them up for going to the FDA

for approval for the use in PTSD of MDMA and it is exciting to think that we could have a medication which is dramatically effective for PTSD. We don't have good medications for PTSD.

Those that are used are modestly effective at both. The best treatments for PTSD are psychotherapies, and the psychotherapies are also modestly effective. This is why we have such a problem with many, many people with PTSD not getting better. That's the promise. The promise is that we might see dramatic improvements in a large number of individuals with PTSD. 

The challenge is really on multiple fronts. First, one of the challenges is the hype that has been promulgated by many, not everyone, but many who are advocating for broad access to these drugs, which includes psilocybin, but also other psychoactive medications which are

currently not approved for medical use. We, as a society, and even we within biomedicine, we tend to think that we're searching for something that's going to cure, that's going to be the answer. The numbers from these studies are really wonderful. The notion that, as you say, 70% lose their diagnosis -- I forget the numbers for true remission, it's less than 70%, but still better than anything else we have on the market -- we look at those numbers and we say, “Ah, we're going to solve PTSD.”

The truth is that even if those numbers are accurate for the general population, it's going to be a very important tool that will help many, many people, but we will still struggle with PTSD amongst veterans, amongst victims of violence, amongst victims of hurricanes and other disasters. But this will help a lot of them and that's really important. 

Another aspect of the challenge is the particular paradigm that MAPS has used in these studies. It is a lengthy paradigm. It is a costly paradigm. And although it may be that you only need it once or maybe only once a year or whatever it is, it is still going to be a tremendous barrier to getting this to people that need it. 

The third challenge that I see -- again, assuming that this data are solid and that it will replicate -- is that because of the barrier to use in the way that MAPS has shown to be effective, there will be a lot of interest, pressure and perhaps even success at going around the strict protocols that MAPS has studied into use paradigms that may not be effective and that could be dangerous. 

So, for example. If MDMA is available through prescription without safeguards required to be used in the context of psychotherapy, we don't know that MDMA by itself without the significant amount of psychotherapy that MAPS has studied with will work for PTSD. Another challenge is that people might want to use it regularly. The likely safety of these compounds in the context of a small number of uses, separated maybe by years at a time -- if it lasts as long as we hope it lasts -- is very, very different from the safety profile of potential regular use of the compounds. And so we have to look at the whole way that we might approach using these

medicines and make sure that it's in in concert with the available evidence. 

There are already states that have -- sorry, I'm not talking about MDMA, I'm talking about psilocybin...I apologize -- but there are states that have already moved towards or passed legislation that legalizes these compounds, which has the potential, yes, to make them available in the context of an evidence-based use, but also has the potential to make them more widely available and they might be particularly dangerous when used in in protocols outside of the evidence-based use.

Shiv: Yeah, I really appreciate that nuanced answer. And certainly it helps counterbalance a lot of the hype. One of one of the best talks I heard at the conference was actually by my advisor, Dr. David Yaden, who's the Roland Griffiths Professor at the Hopkins Center for Psychedelic and Consciousness Research. He talked about the potential of having a ‘wet blanket award’ where we actually recognize people who publish data that shows the risks or that help reduce the hype, because we've been here before in the 1960s and 70s where the hype kind of went further than the science and then set back the field for several decades. So, being able to temper that, as you suggest and as you've written about and spoken about, I think is very important. 

Speaking of Dr. David Yaden, one of the reasons I've gravitated towards going back to med school at Hopkins and working with him in his lab is that there's abnormal psychology, PTSD, anxiety, depression, etc., and then there's positive psychology, which is how do we help people flourish and be the most fulfilled they can be? I'm just curious, do you or the NIMH have any research or studies in that field? Like, how do you think about that spectrum from abnormal to positive psychology?

Dr. Gordon: I would say that we at NIMH feel that our responsibility is in research to alleviate suffering. The notion of trying to enhance someone's well-being more generally is linked to that elimination of suffering, but we focus on those aspects of well-being that pose risk versus resilience towards mental illness. So, if we are going to study a process that enhances well-being, we are going to do it in terms of understanding its relationship to risk and resilience to mental illness, as opposed to well-being for its own sake because we are funded by the taxpayers of the United States of America, and their mandate to us is to help prevent, treat and cure mental illness. So, that's our mission. We try to stick close to that mission.

Shiv: Very helpful. Thank you. My last question for you is, what advice generally would you give to our audience about meeting the challenges of this moment, given that so many of them are current or future health care professionals?

Dr. Gordon: Well, I would say to the current and future health care professionals listening in, take care of yourself and take care of your patients and that means both their mental health as well as other forms of health.

Shiv: Right. That’s really important advice. Well, with that, Dr. Gordon, I'd like to thank you for taking the time to be with us on the Raise the Line podcast and more importantly, for the work that you and your team have been doing to alleviate mental health suffering around the nation and beyond. So, again, thank you for your time.

Dr. Gordon: Thanks for having me, Shiv.

Shiv: Great. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show. And remember to do your part to raise the line and strengthen our health care system. We're all in this together. Take care.