NIMH Alliance for Research Progress Meeting Summary - July 23, 2010
The National Institute of Mental Health (NIMH) convened its thirteenth meeting of the Alliance for Research Progress (Alliance) on Friday, July 23, 2010 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 mental health research, to network with colleagues, and to interact directly in a day-long meeting 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 major NIMH projects as well as the status of current events affecting the mental health community—domestically and abroad. During the afternoon session, Pamela S. Hyde, J.D., Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) presented information on the challenges involved in implementing health care reform and parity in health insurance coverage for mental health and substance abuse. For more information on the speakers, please see the attached agenda and participant list.
State of the NIMH
Dr. Insel welcomed Alliance members and noted that two overriding topics have been in the news since the last Alliancemeeting—health care reform and mental health parity. He reviewed the four Ps associated with the four objectives of the NIMH Strategic Plan (pathophysiology, predictive medicine, preemptive and personalized interventions, and public health impact). His presentation focused on preemptive and personalized interventions, discussed lessons learned from NIMH effectiveness trials (CATIE, STAR*D, and STEP-BD), and described new directions for the National Institutes of Health (NIH) regarding drug development. Dr. Insel stated that the trials have taught us that a next generation of truly novel medications is needed, and that while the current medications are often necessary, they are rarely sufficient. He told Alliance members that the pharmaceutical and biotechnology industries are focusing more on immunology and cancer treatments in 2010 and moving away from the development of medications targeting the central nervous system. He talked at length about the investment of resources and time needed to develop effective antipsychotic medications throughout the drug development pipeline. Finally, he discussed the Cures Acceleration Network, which was authorized in Public Law 111-148, the Patient Protection and Affordable Care Act (ACA), and how NIH will begin to increase its work on drug development. While this represents a challenge for the agency, Dr. Insel noted that initial building blocks for this endeavor exist through the molecular libraries project and a recent NIH/ Food and Drug Administration partnership. By using novel approaches to drug development based upon the pathophysiology of mental disorders, NIH will be positioned to develop personalized and preemptive therapeutics that could dramatically impact the public health.
Army Study to Assess Risk and Resilience in Service Members
Lisa Colpe, Ph.D., M.P.H., Chief of the Office of Clinical and Population Epidemiology Research in the Division of Services and Intervention Research (DSIR) presented information on the Army Study to Assess Risk and Resilience in Service Members (Army STARRS). The purpose of the study is to facilitate the development of empirically based methods for improving soldiers’ overall mental health and behavioral functioning, and to prevent suicidal behaviors. This will be accomplished by identifying salient and modifiable risk and protective factors and delivering “actionable” findings rapidly. The study, developed in response to the increasing rates of suicide among members of the military, is the largest study of suicide and mental health among military personnel ever undertaken. Funded through a cooperative agreement between NIMH and the U.S. Army, the total cost of the study is approximately $60 million over a 5-year period. Dr. Colpe noted that pilot studies are underway and discussed the four main study components:
- Historical Data Study: examines historical data from Army and Department of Defense sources on suicide events among all soldiers who served on active duty since January 1, 2004 to detect risk and protective factors related to psychological resilience, mental health, risky behaviors, and suicide.
- New Soldier Study: consists of multiple data collection modules during basic combat training to assess new soldiers' health, personal characteristics, and prior experiences.
- All Army Study: focuses on a single data collection visit to selected units, beginning with units in the pre-deployment stage, to assess psychological and physical health; events encountered during training, combat, and non-combat operations; and life and work experiences across all phases of Army service.
- Soldier Health Outcomes Study: conducts interviews of relatives of deceased soldiers, suicide attempters, and controls in an attempt to identify characteristics, events, experiences, and exposures that predict positive or negative health and behavior outcomes.
Additional information can be found on the Army STARRS page.
Recovery After an Initial Schizophrenia Episode
Amy Goldstein, Ph.D., Chief of the Child and Adolescent Preventive Intervention Program in DSIR discussed the NIMH Recovery After Initial Schizophrenia Episode (RAISE) project. She told Alliance members that RAISE was designed to reduce the likelihood of long-term disability which is often experienced among individuals with schizophrenia, a disorder whose symptoms usually develop in adolescence or early adulthood. She discussed the economic burden of the disorder on individuals, their families, and the public health system, and explained that the primary objectives of RAISE were to:
- Design and test effective interventions for early phase schizophrenia;
- Engineer rapid adoption and implementation of effective treatment packages by engaging “end users” at the start of intervention development;
- Assess clinical, functional, and economic outcomes; and,
- Generate information relevant to key stakeholders, including health care policy makers.
Dr. Goldstein reviewed the overall project structure and noted that NIMH has awarded research contracts to two independent research teams. Each team has developed different intervention approaches that will be tested in real world settings. She mentioned that NIMH held a meeting of stakeholders in July 2009, when the contracts were first awarded, to introduce the project and obtain feedback on the interventions. This valuable feedback informed the overall RAISE Project and helped the research teams to refine the final study designs. Known as the RAISE Early Treatment Program and the RAISE Connection Program, the research teams will begin testing the feasibility of their interventions in late 2010.
Behavioral Health 2010: Challenges and Opportunities
Pamela S. Hyde, J.D., Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) presented a unique prospective of the challenges and opportunities facing the mental health community as a result of the Patient Protection and Affordable Care Act (ACA) and the implementation of mental health parity. Her presentation focused on three topics – how the ACA will change behavioral health services for individuals and families, the role of states and providers in implementation of the ACA, and key limitations associated with mental health parity. She discussed SAMHSA’s mission, which is to reduce the impact of substance abuse and mental illness on America’s communities, and highlighted several of the agencies strategic initiatives which enable the agency to provide focus to its budget planning process; align resources; and create consistent messages. She noted that the ACA will significantly enhance access to care and services for persons with mental illness or substance abuse disorders, and described key elements of the ACA with regard to coverage, services, prevention, and training.
- Coverage – Expands Medicaid to 133% of the federal poverty level; extends coverage though parental health insurance through age 26; and, expands options in home and community-based services for individuals with mental illness or substance abuse disorders.
- Services – Allows state Medicaid programs to establish health homes for persons with long term illnesses (including mental illness and/or substance use disorders); requires parity in essential benefits plans offered through exchanges and in private health plans that choose to offer services for mental and substance abuse disorders; establishes grants to community mental health programs for co-locating primary and specialty care services; and, establishes a voluntary, self-funded long-term care insurance program for people currently employed (CLASS Program) and a “Medicaid Emergency Psychiatric Demonstration.”
- Prevention – Establishes a national public/private outreach and education campaign and a Prevention Trust Fund; supports the development of prevention research programs and national prevention plans; calls for coverage of prevention services in private insurance and Medicare; and, allows Medicare payments for annual wellness visits, including assessments and recommendations to address mental health conditions and risks.
- Training and Research – Calls for increased patient-centered health research and training grants for behavioral health workforce; and, calls for training on mental health and substance use disorders for primary care providers.
Ms. Hyde highlighted the role of states and providers in implementing the ACA. States will have to prepare for the expansion in their role as payer and expanded enrollment in State Medicaid program. Providers will also prepare for implementation by developing strategic partnerships and workforce competency, and improving infrastructure. Ms. Hyde told Alliance members that a great deal of work remains to be done and encouraged the group to become familiar with healthcare.gov web site.
Ms. Hyde briefly discussed the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Interim Final Regulations that went into effect on June 10, 2010. She noted that one of the biggest challenges of the Act will be ensuring that comparable medical/surgical and behavioral health services are provided. She detailed both the quantitative and non-quantitative treatment limitations, and provided rules for each.
Mental Health Disparities: A Global Perspective
Pamela Y. Collins, M.D., M.P.H., Associate Director for Special Populations and Director of the Office for Research on Disparities and Global Mental Health (ORDGMH) and the Office of Rural Mental Health Research focused her presentation on three topic areas—global mental health as it relates to mental health disparities, the need for integration of mental health into global public health activities, and the strategy of her office to address arising needs. She talked about global health being informed by social, political, and economic interconnections which make borders and boundaries less relevant today. With regard to global mental health, Dr. Collins noted that while several neuropsychiatric conditions have been identified as leading causes of the global burden of disease, very few countries allocate funds for these conditions in health budgets.1 She provided an historic overview of the evolution of mental health services in wealthy and poor countries, encompassing the rise and fall of asylums in wealthy countries, as well as the development of colonial psychiatry and modern health services. She noted that poor countries do not have the same human resources (e.g., psychologists, psychiatric nurses, etc.) as wealthier countries, and that many have established mental health programs within the past 20 years. She also spoke about mental health disparities that exist within the United States, specifically the prevalence of common mental disorders among racial and ethnic minority groups, as well as disparities in access to and quality of care. Dr. Collins talked briefly about the benefits of an integrated approach to addressing global mental health issues and disparities, noting their relevance to the challenges outlined in the United Nations Millennium Development Goals. In closing, Dr. Collins highlighted elements of the ORDGMH’s strategy to address the needs of the field, strengthen collaborations with international organizations, and build capacity for research.
|Photographs from the NIMH Alliance for Research Progress Meeting Summary|
Alliance members listening to presentations
Alliance members sharing their views
Dr. Insel responding to comments
Invited speakers (L to R): Pamela Collins, M.D., M.P.H.;
Pamela Hyde, J.D.; Amy Goldstein, Ph.D.; and Lisa Colpe, Ph.D.
NIMH Director, Dr. Thomas Insel conversing
with SAMHSA Administrator, Pamela Hyde, J.D.
1The global burden of disease: 2004 update. World Health Organization. WHO Press. Geneva, Switzerland. 2004