I recently had a very helpful meeting with representatives of several graduate schools of social work. Their main question: is NIMH interested in public health impact as defined in the fourth Strategic Objective of the NIMH Strategic Plan released in 2008? The Strategic Plan laid out in four objectives what, at first glance may seem to be a stepped process for transforming the understanding and treatment of mental disorders, from research on basic processes (Objective 1) to understanding how these disorders develop across the lifespan (Objective 2), to intervening based on that understanding (Objective 3), and finally to improving public health through the connection of research to mental health care (Objective 4).
This progression has been an important tool for our planning processes since 2008, but in actuality doesn’t begin to capture the complexity of the many ways in which the research we support will have its ultimate impact on public health. As we know from other areas of biomedical research, scientific progress for public health is a more complicated, iterative process that usually does not follow a linear progression.
Let’s take the example of prevention research. Prevention research, among our highest priorities, is based on understanding individual risk and developing innovative treatments to preempt disability. In addition to last week’s meeting with leading social workers, the Institute has received a number of inquiries about our investment in prevention research with the assumption that most of this investment would fall in the last step of our process, Objective 4.
However, prevention research is represented in each of our objectives because effective prevention comes from understanding the underlying biology of risk, so that we can effectively preempt the disability associated with these disorders. For schizophrenia, bipolar disorder, autism, and most mood and anxiety disorders, we know very little about predicting individual risk and we lack vaccines or powerful universal preventions. NIMH supports research on risk factors for these disorders (Objective 1 and 2), research on ways of intervening to mitigate those risk factors (Objective 3), and research to ensure effective interventions reach as many of the people who need them as possible (Objective 4). Overall, prevention research represented a $283M investment in 2010, up 36% from 2008 when the Strategic Plan was launched.
As an additional example, the Institute also makes substantial investment in research that seeks to improve access, quality, and economic impact of mental health care, and ensure that evidence-based interventions are disseminated and widely implemented. Some may assume that all of this research on services would fall within Objective 4 of our Plan, and indeed, much of it does. Yet, because all these factors should be considered when developing new interventions, services research is also closely tied to other aspects of clinical research, as described in Objective 3 of the Plan, which focuses on investing to “strengthen the application of mental health interventions in diverse care settings by examining community and intervention delivery approaches and how they may affect intervention outcomes.” Investment in health services research, in 2010 over $106M, has increased 13% since 2008.
NIMH’s communication and partnership efforts are also an important component of Objective 4. The Institute takes seriously its role in informing the public about mental disorders, mental health care, and related research. Last year alone, we distributed over 2.2 million pamphlets and booklets on mental health issues to the public and answered 25,000 public inquiries. Additionally, we work directly with our 55 partners in the mental health service system through the Outreach Partnership Program, a nationwide initiative working to increase the public’s access to science-based mental health information through partnerships with national and state nonprofit organizations in every state.
This brings me to my last, and perhaps most important, point. Interpreting NIMH’s Strategic Plan as a strict step-by-step progression means that the process would end with a simple hand-off of research results to the mental health service system, leaving the system to determine what to do with it. But again, this model is simply not adequate for dealing with the complexities of mental health care.
Researchers, practitioners, policymakers, patients, and families all have a role to play in tackling this challenge and much can be accomplished by working together collaboratively. In order to capitalize on this type of collaboration, the Institute recently launched its Mental Health Research Network, a consortium of 10 (soon to be 11) public-domain research centers affiliated with not-for-profit integrated health systems. These systems provide care to a diverse population of more than 10 million people in 11 states, and share rich and compatible data resources to measure the impact of treatment as it is happening.
One study soon to be piloted in this network will examine over time how suicide warning labels on antidepressants affect later suicidality among youth. Another will look at effectiveness of a new type of therapy for postpartum depression. By linking research so closely to practice, we will work to transcend the compartmentalized “linear progression” and, instead, work together to create a “learning mental health system,” a system in which practice, policy and research are interconnected. Or, as Greg Simon, the principal investigator on this Network said at the NIMH Coalition for Research Progress meeting last week, “we need to go from ‘translating research into practice’ to ‘transforming practice into research’.” Innovations such as this and our many cross-Objective research goals will provide the fastest and most effective way of changing the public mental health landscape, to more quickly improve the lives of people with mental illness.
- Chambers DA, Wang PS, Insel TR. Maximizing efficiency and impact in effectiveness and services research. Gen Hosp Psychiatry. 2010 Sep-Oct;32(5):453-455. Epub 2010 Aug 24. PMID: 20851264
- Insel TR. Disruptive Insights in Psych. Journal of Clinical Investigation. 2009 Apr;119(4):700-705. Epub April 1. PMID: 19339761
- Simon GE, Ludman EJ. It’s time for disruptive innovation in psychotherapy. Lancet. 2009 Aug;374(9690):594-595. PMID: 19699995