The National Institute of Mental Health (NIMH) convened its twelfth meeting of the Alliance for Research Progress (Alliance) on Friday, January 15 in Bethesda, Maryland; this document provides an overview of the proceedings. The meeting served as an opportunity for participants to hear about exciting new research and advances in the field, to network with colleagues, and to interact directly with the NIMH director, Thomas Insel, M.D., and senior NIMH staff. Invitees included representatives from national voluntary organizations representing individuals and families affected by mental illness. Participants heard presentations on future directions for NIH, mental health parity and health care reform, and health risks in individuals with severe mental illnesses. Guest speakers included Francis S. Collins, M.D., Ph.D., NIH Director; Richard Frank, Ph.D., Deputy Assistant Secretary for Planning and Evaluation, Office of the Secretary, Department of Health and Human Services (HHS); Henry T. Harbin, M.D., Health Care Consultant and former Chief Executive Officer and Chairman, Magellan Health Services; and John Newcomer, M.D., the Gregory B. Couch Professor of Psychiatry, Psychology, and Medicine, Washington University School of Medicine. NIMH staff also presented information on three concept clearances (Study of Health Outcomes in Autistic Children and their Families; Development of a Clinically Useful Classification of Mental Disorders for Global Primary Care; and, Implementation Science for the Mental Health Gap Action Program), which the Alliance unanimously approved.
State of the NIMH
Dr. Insel welcomed participants and opened the meeting with his State of the NIMH address, which highlighted three major themes—genetics research, the impact of American Recovery and Reinvestment Act of 2009 (ARRA) funding on implementing the NIMH Strategic Plan, and HIV/AIDS research. In tribute to the recent passing of Jerilyn Ross, the president and chief executive officer of the Anxiety Disorders Association of America, Dr. Insel acknowledged her contributions to the field and as an active member of the Alliance. He discussed the “Genetic Revolution,” and the wealth of scientific information that has been discovered through NIH-funded projects such as the Human Genome ProjectExternal Link: Please review our disclaimer. (2003), the Human HapMapExternal Link: Please review our disclaimer. Project (2005), the Structural Variations in the Genome projects (2007), and the Human Epigenome projects (2009). He went on to discuss how research has revealed the complexity of genes and genetic mutations, and how some illnesses occur as a result of a single mutation, while others may be the result of multiple mutations or certain variations of mutations. He spoke about what has been learned about common variants relating to schizophrenia, bipolar disorder, attention deficit and hyperactivity disorder, autism spectrum disorder (ASD), major depression, obsessive compulsive disorder, and treatment responses to antidepressants through genome-wide association studies (GWAS). Dr. Insel also told the participants about the new challenge of learning how areas of the brain are connected and ongoing research to develop a ‘wiring diagram’ of the brain—the Human Connectome Project.
Dr. Insel discussed the $10.4 billion NIH received in ARRA funds and how NIMH has used the approximately $366 million it received to stimulate economic recovery through discovery. In addition to funding meritorious research applications submitted in response to ARRA, NIMH used funds for three signature projects: the Army Study to Assess Risk and Resilience in Soldiers (Army STARRS); Recovery After an Initial Schizophrenic Episode (RAISE); and, the Transcriptional Atlas of Human Brain Development. ARRA funds were also used to advance the short-term objectives of the Interagency Autism Coordinating Committee's (IACC) Strategic Plan for Autism Spectrum Disorder ResearchExternal Link: Please review our disclaimer., and to support research addressing the heterogeneity of ASD. Dr. Insel told Alliance members that global mental health is also a priority area for NIMH and NIH, and that global health is not the same as foreign health. The world is more connected now than in the past, and the boundaries that once separated people and illnesses no longer exist. He also discussed the Institute’s new approach to HIV/AIDS research and changes to funding opportunity announcements throughout NIMH.
Cardiometabolic Risk in Individuals with Mental Illness
John Newcomer, M.D., talked to Alliance members about increased cardiometabolic risks and premature mortality in individuals with mental illness. He stated that persons with severe mental illness lose 25–30 years of life expectancy when compared with the general population and that cardiovascular disease is a primary cause of death in this population.1 He discussed findings from his research and expanded upon five key factors contributing to the increased deaths due to cardiovascular disease among persons with mental illnesses despite a decline in the general population2:
- Increased modifiable health risk factors—including increased rates of lipid abnormalities, diabetes, hypertension, metabolic syndrome, and smoking, and decreased rates of physical activity
- Decreased access to or utilization of medical care
- Decreased adherence to therapies
- Decreased economic capabilities
- Decreased opportunities for primary and secondary prevention for mentally ill individuals in comparison to the general population (for example, mentally ill individuals are less likely to be screened or treated for dyslipidemia, hyperglycemia, or hypertension; less likely to receive angioplasty or coronary artery bypass graft—CABG; less likely to receive drug therapies of proven benefit following a heart attack; and are more likely to have premature mortality following or after a heart attack).
Dr. Newcomer highlighted findings from the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study as it relates to metabolic disorders in individuals with mental illnesses. He also detailed how certain antipsychotic treatment therapies cause increased weight gain, therefore putting individuals with mental illnesses at increased risk for other health problems such as heart attack, obesity and diabetes. He discussed how clinicians can beneficially modify patient risk through the use of monitoring and interventions, including use of medications with lower potential for adverse metabolic effects.
Health Care Reform and Mental Health Parity
Richard Frank, Ph.D., provided an overview of the current environment at the HHS-level concerning mental health policy issues such as parity and comparative effectiveness research (CER). He told Alliance members about the important role advocates play in promoting mental health policy, and described the purpose and role of the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in policy analysis. Dr. Frank discussed the upcoming release of regulations governing implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Parity law) and the implications for stakeholders including payers, consumers, clinicians, and the public. These regulations will address areas of ambiguity in the Parity law and address issues related to scope of care, defining length of care (long vs. short term), and establishing comparable approaches for mental health and substance use disorders and other medical care. He also talked about CER and the challenges it presents to policy makers. Specifically, he discussed the difficulties in determining the prevention needs of individuals without access to health care, and examined policies and organizations and consumer engagement strategies that best promote good matches between patients and treatments.
Henry Harbin, M.D., discussed key aspects of the Parity law and components of draft health care reform legislation. He noted that the Parity law went into effect on January 1, 2010 and that although the regulations associated with the law have not yet been released (Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; Final RuleExternal Link: Please review our disclaimer. (PDF file, 48 pages)), health plans must implement the law. He detailed two issues to be addressed in the regulations:
- Scope of Service: will plans have to provide parity in range and scope of treatment services for mental health or substance abuse disorders versus medical or surgical conditions?
- Medical Management: will plans have to provide parity in medical management interventions, for example, utilization review, experimental versus non-experimental determinations?
He explained that mental health parity includes a wide range of treatment and services and without clearly defined scope there is no protection for the need for care; the determination of the type of care/services provided is left to the discretion of the health plans. With regard to medical management, Dr. Harbin noted that there is concern that certain evidence-based treatments may not be reimbursed by health plans and provided examples where the effectiveness of certain medical services were questioned and not reimbursed.
Alliance members engaged Dr. Frank and Dr. Harbin in dialogue about the Parity law and how the issues concerning scope and medical management will affect their constituents. Questions related to reimbursement for consumer-support interventions (when a family member acts as a provider), access to care, and concerns about the implementation of evidence-based mental health treatments were actively discussed. Dr. Harbin noted that the advocacy community should lead the effort for inclusion of coverage mandates in health plans. He recommended that Alliance members work together to evaluate patterns for health reimbursement and medical management strategies. He said that it would be a challenge for NIMH and the Substance Abuse and Mental Health Services Administration (SAMHSA) to present the issues of mental health populations and communities to policy makers in a clearer manner. Dr. Frank mentioned that the established evidence base should be regarded in the forth coming regulations.
NIH Director’s Report
Alliance members were pleased to welcome NIH Director, Francis S. Collins, M.D., Ph.D. who discussed the NIH budget and the five programmatic areas that will direct future research at the agency. Dr. Collins stated that NIH is the steward of medical and behavioral research for the Nation and that the agency’s mission is science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability. To fulfill this mission, NIH allocates more than 80 percent of its budget to extramural research, approximately 10 percent to support a core program of basic and clinical research known as the Intramural Research Program, and the remainder for research management and support and facilities costs. He noted that NIH received $30.988 billion in the FY2010 budget appropriation and awaits news on the FY2011 President’s Budget. Dr. Collins told Alliance members that much of the more than $10 billion awarded to the agency through ARRA has been allocated, with $8.2 billion going to research, $1 billion to extramural repairs and improvement, $0.5 billion to intramural repairs and improvement contracts, and $0.3 billion for scientific equipment. Approximately half of the funds have been awarded as of January 5, 2010. He noted that the two-year estimated job creation and retention rate as a result of NIH ARRA funding is 50,000 jobs across the country.
Dr. Collins discussed the five programmatic areas that are ripe for major advances and that could reap substantial downstream benefits to the scientific community and the world. The five areas are:
- Applying genomics and other high throughput technologies
- Translating basic science discoveries into new and better treatments
- Using science to enable health care reform
- Focusing on global health
- Reinvigorating the biomedical research community
During the discussion periods, Dr. Insel, speakers, and NIMH staff responded to inquiries and concerns voiced by Alliance members. Throughout the day, Alliance members reiterated that they would be more effective if they worked together to promote one voice in publicly addressing mental health issues rather than individually promoting multiple issues. Participants suggested that NIMH lead the effort in increasing awareness about mental illnesses through a public campaign. Dr. Insel noted that the Institute is currently conducting an assessment of its communication efforts to determine future strategies. In response to an inquiry regarding the public trust, Dr. Insel said that NIMH has been proactive in addressing issues with grantee institutions surrounding financial conflicts of interest and that NIH is working on a new policy which will be posted for public comment in the spring. In closing, Dr. Insel summarized the key points discussed during the meeting and thanked Alliance members for providing helpful feedback. He reinforced that the meeting serves as a valuable opportunity for NIMH to get essential feedback from national voluntary and advocacy organizations that represent NIMH's most important stakeholders--individuals and families coping with mental illness. He thanked them for actively participating in the Alliance, and forfostering the dialogue that is so critical to decisions involving the future path and directions of NIMH-funded research.
|Alliance for Research Progress (Alliance)|
Speakers (L to R): Dr. Frank, Dr. Wang, Dr. Insel, Dr. Newcomer, and Dr. Harbin
NIH Director, Francis S. Collins, M.D., Ph.D. addressing the Alliance
1Lutterman et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003.
2Newcomer J. Hennekens CH. JAMA 2007; 298(15):1794-1796