NAMHC Minutes of the 239th Meeting
September 18, 2014
Department of Health and Human Services
Public Health Service
National Institutes of Health
National Institute of Mental Health
The National Advisory Mental Health Council (NAMHC) convened its 239th meeting open policy session at approximately 8:30 a.m. on September 18, 2014, in the Neuroscience Center in Rockville, Maryland, and adjourned at approximately 12:30 p.m. In accordance with Public Law 92-463, the policy session was open to the public. The NAMHC reconvened for a closed session to review grant applications at 1:30 p.m. on September 18, 2014, in the Neuroscience Center in Rockville, Maryland, until adjournment at approximately 5:00 p.m. (See Appendix A: Review of Applications). Thomas Insel, M.D., Director of the National Institute of Mental Health (NIMH) presided.he National Advisory Mental Health Council (NAMHC) convened its 238th meeting in closed session to review grant applications via teleconference. The meeting began at approximately 2:00 p.m. on August 26, 2014, and adjourned at approximately 3:30 p.m. Thomas Insel, M.D. Director, National Institute of Mental Health (NIMH) presided.
Council Members Present at the Grant Review and/or Open Sessions
(See Appendix B: Council Roster)
- Thomas R. Insel, M.D.
- Jane A. Steinberg, Ph.D.
- Patricia A. Areán, Ph.D.
- Deanna Barch, Ph.D.
- Virginia Trotter Betts, M.S.N.
- David A. Brent, M.D.
- Randall Carpenter, M.D.
- B.J. Casey, Ph.D.
- Lisa Greenman, J.D.
- Hakon Heimer, M.S.
- Richard L. Huganir, Ph.D.
- Steven E. Hyman, M.D.
- Marsha M. Linehan, Ph.D. (by telephone)
- Maria A. Oquendo, M.D.
- Gene Robinson, Ph.D.
- Mary Jane Rotheram, Ph.D.
- Gregory E. Simon, M.P.H., M.D.
- J. David Sweatt, Ph.D.
- Carol Tamminga, M.D.
- Hyong Un, M.D.
Ex Officio Members
- John W. Davison, Ph.D., M.B.A., Department of Defense
- Ira Katz, M.D., Ph.D., Department of Veterans Affairs
- Paolo del Vecchio, M.S.W., Substance Abuse and Mental Health Services Administration (SAMHSA)
Others Present at the Open Policy Session
- Tyauna Brown, Synergy Enterprises, Inc.
- Michael Byer, M3 Information
- Mark Egan, Alderson Reporting Company
- Craig Fisher, American Psychological Association
- Justin Harding, The National Association of State Mental Health Program Directors
- Zachary Kahan, American Association of Child and Adolescent Psychiatry
- Siobhan Morse, Foundations Recovery Network
- Steven Saenz, NIH Interpreter
- Andrew Sperling, National Alliance on Mental Illness
- Lori Whitten, Synergy Enterprises, Inc.
- Daniel Vega, NIH Interpreter
- TaRaena Yates, Synergy Enterprises, Inc.
Open Policy Session Call to Order and Opening Remarks
NIMH Director Thomas Insel, M.D., called the open policy session to order and welcomed all in attendance.
Approval of Minutes of the Previous Council Meetings
Turning to the minutes of the August 2014 teleconference and the May 2014 Council meeting, Dr. Insel asked whether Council members had any comments, revisions, or questions about the minutes. As he received none, the motion to approve the minutes was unanimously passed.
NIMH Director’s Report
Dr. Insel reviewed the agenda for the open policy session and provided an update on activities related to NIMH.
The Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative continues to advance. The White House is planning a meeting of private partners—companies (e.g., Google and Microsoft) and foundations (e.g., the Paul G. Allen Family Foundation)—to make the effort a public-private endeavor. The White House views the BRAIN Initiative as a high priority, and the signature science initiative of the President’s second term. The meeting of private partners will convene at the end of September and will build on the President’s remarks to the American Legion on August 28. In those remarks, the President spoke of the need to provide better care to veterans with neurological and psychiatric problems (e.g., traumatic brain injury [TBI] and post-traumatic stress disorder [PTSD]). Research conducted under the BRAIN Initiative can in turn lead to better care for those with TBI, PTSD, and other conditions.
At the Congressional level, members of Congress recently debated two bills related to mental health care. Representative Tim Murphy, Ph.D. (R-PA), has introduced a major piece of legislation to reform mental health care. As part of Representative Murphy’s efforts, there has been a series of congressional hearings and briefings on mental health. Congressman Ron Barber (D-AZ) has also introduced legislation dealing with reform of the mental health system. In a separate effort, under the leadership of Congressman Fred Upton (D-MI) and Diane DeGette (D-CO) the House Energy & Commerce Committee is working to increase national awareness about the importance of biomedical research with the 21st Century Cures Initiative. The Committee is involving National Institutes of Health (NIH) Director, Francis Collins, M.D., Ph.D., as well as patient and family advocates.
On August 8, the Autism Collaboration, Accountability, Research, Education and Support (CARES) Act of 2014 (P.L. 113-157) was signed into law. This law re-establishes an interagency coordinating committee that will focus on autism-related services and research. The law also creates a new autism oversight position at the Department of Health and Human Services (HHS) for coordination and tracking of what is happening in the field. There is great interest in the youth transition from school-based services to adult services, and this topic is the subject of an upcoming Congressional report. Dr. Insel noted that NIMH released a set of Requests for Applications (RFA) in that area (e.g., RFA-MH-14-100), and the Institute has made several awards to date.
At the HHS level, Secretary Sylvia Burwell has had a busy first few months. The foci of the past several weeks have been the Ebola virus and laboratory safety. As expected, a great deal of work is going into implementing the Affordable Care Act (ACA) and the Mental Health Parity Act. Marijuana is another topic of discussion, given recent changes in state laws. There is also emerging interest in serious mental illness. The Substance Abuse and Mental Health Services Administration (SAMHSA) and NIMH are collaborating on two projects. In fulfillment of a congressional mandate, SAMHSA’s Mental Health Block Grants include a five percent set-aside for implementing Coordinated Specialty Care (CSC). CSC is based on NIMH’s Recovery After an Initial Schizophrenic Episode (RAISE) Initiative. The goal is to support evidence-based programs that address the needs of individuals with early-stage serious mental illness. By the end of September 2014, the agencies expect all 50 states and 8 territories to develop a pathway for implementing CSC. The NIMH and SAMHSA teams worked together to prepare calls for proposals, make awards, and report to Congress. In a second collaborative project, SAMHSA and NIMH are collaborating to include measures of mental illness in the National Survey on Drug Use and Health. Dr. Insel commented that these are groundbreaking efforts that will have a significant and enduring impact.
Other current NIH efforts of interest include the Genomic Data Sharing Policy (NOT-OD-14-124) released at the end of August. This policy states the expectation that raw data from large-scale “-omic” studies (both human and nonhuman) will be shared. The policy, which sets expectations for access to such data, goes into effect in January 2015 and is the fruit of a two-year effort. Many researchers are already sharing such data. In June 2014, NIMH announced its expectations for broad data sharing of data from clinical trials (NOT-MH-14-015). This policy, like the Genomic Data Sharing Policy, is part of a larger culture change and the movement towards openness in biomedical science occurring over the past two decades. Data sharing is about getting the most value from the Nation’s research investment. When data are shared and reanalyzed, the results and interpretation can differ from those of individual experiments (as demonstrated in Reanalyses of Randomized Clinical Trial Data, JAMA, September 10, 2014, by John Ioannidis and colleagues).
NIH is also focusing on laboratory biosafety. During the summer, there was a discovery of the smallpox virus in a vacant Food and Drug Administration (FDA) laboratory on the NIH campus. The vial containing the virus had been undisturbed since 1954, and there was no danger or harm. However, the discovery raised the important question of what other materials may be stored at NIH and in other laboratories around the country. NIH and other agencies conducted sweeps of their intramural laboratories for various pathogens and toxins. NIH has also recommended a sweep of extramural laboratories.
NIMH is creating a new unit for the Research Domain Criteria (RDoC) project, which addresses new ways of classifying psychopathology based on dimensions of observable behavior and neurobiological measures. Bruce Cuthbert, Ph.D., will lead the office, which will focus on developing an information commons and establishing timelines for deliverables. RDoC efforts will be useful for both clinicians and the research community.
Another change at NIMH is the formation of a new Division on October 1, 2014—the Division of Translational Research—which combines the Division of Adult Translational Research and Treatment Development and the Division of Developmental Translational Research. The new Division will act as a bridge between basic and applied research. Philip Wang, M.D. , Dr.P.H., will serve as Acting Division Director. NIMH is actively searching for a permanent director for the Division, and Dr. Insel suggested that Council members encourage qualified and interested candidates to apply
The NIMH Division of AIDS Research (DAR) focuses on basic neuroscientific AIDS research as well as basic and applied behavioral science; DAR traditionally receives 12–14 percent of the Institute’s budget. AIDS research at the National Institute of Allergy and Infectious Diseases (NIAID) primarily focuses on HIV eradication. Based on a review of AIDS research at NIH by the Office of AIDS Research and ongoing review by the Advisory Committee to the NIH Director (ACD), NIH is shifting its emphasis to research that integrates behavioral and biomedical approaches more effectively. As a result, FY2014 funds ($27 million) for NIMH AIDS shifted to NIAID (although NIMH can access these funds), and the NIMH DAR is now co-located with NIAID’s AIDS program. DAR is also pursuing behavioral research under the President’s Emergency Plan for AIDS Relief Program. These changes at NIMH anticipate NIH’s desired approach of program integration and a strategic focus on AIDS-related needs.
The FY2014 NIH program budget level was $30.15 billion, which was a $1 billion increase over FY2013 (though $0.71 billion below FY2012). The FY2014 budget included a specific increase of $22 million for the BRAIN Initiative and a general increase of 3 percent over FY2013 for Institutes and Centers (ICs). The President’s budget for FY2015 sets the NIH program level at $30.36 billion, which represents a $200 million increase over FY2014, but is still $0.5 billion below FY2012. The Government is operating on a Continuing Resolution until December 11, and the House passed another Continuing Resolution (which the Senate is expected to pass in turn). Under a Continuing Resolution, agencies continue to operate with the previous year’s budget but cannot start any new programs. This situation will likely continue through the Presidential election in 2016. Sequestration returns in FY2016, which will result in a 5 percent budget cut across the entire Government unless Congress finds a solution. Dr. Insel remarked that as NAMHC members make decisions about funding research, they might consider the outlook of Continuing Resolutions and a sequester (unless something changes) over the next couple of years. These are fiscally tough times, with reduced purchasing power relative to inflation, and NIMH appreciates the Council’s advice on strategic research investments.
The NIH Common Fund’s Single Cell Analysis Working Group, which NIMH co-leads, announced the launch of the Single Cell Analysis Program Challenge in August. This is a prize competition that seeks novel robust methods that can analyze individual cells and detect and assess changes in cellular behavior and function over time.
Regarding the NIH BRAIN Initiative, the ACD received the scientific plan, Brain 2025: A Scientific Vision, in June. This report is explores the potential outcomes of the BRAIN Initiative. During the next five years, the BRAIN Initiative will emphasize technology development and the creation of neurotechnologies for decoding brain function. Five years beyond that, researchers will use these tools for discovery-driven science, with a focus on mapping circuits. To map the circuits of the brain, researchers will measure the fluctuating patterns of electrical and chemical activity flowing within those circuits to understand how their interplay creates our unique cognitive and behavioral capabilities. Over the past decade, researchers have done well at molecular and cellular mapping (the microlevel) and at the level of human brain imaging (the macrolevel). But we need a high-definition rendering of the intermediate level, and the Initiative will support projects to achieve this goal. The report recommends a budget, with a total investment of $4.5 billion by FY2025, including suggestions for training infrastructure. The technology aspect of the Initiative is unique, very ambitious, and exciting. Some members of Congress are particularly enthusiastic about the BRAIN Initiative. However, it is uncertain whether Congress as a whole will agree to the recommended budget, and there is a need to convince people that this science is a good investment.
Researchers submitted more than 300 applications for the first set of BRAIN Initiative RFAs (FY2014). After an intense review process, NIH will fund 58 projects in the areas of cell-type classification, novel tools for identifying cells and circuits, next-generation human imaging, large-scale recording and modulation technologies, and integrated approaches to understanding circuit function. Many projects involve people from fields that have not traditionally studied the brain, which should spark creativity and advance innovation.
B.J. Casey, Ph.D., expressed excitement about work to improve services for people with autism during the transition from adolescence to adulthood. She remarked that such services are important for people with other mental illnesses as well—a point that many Council members have raised previously. Dr. Insel agreed and suggested that NIMH address this topic in its next set of concepts and strategic plan development process. There has been a good response with the autism effort, including philanthropic investment.
Deanna Barch, Ph.D., applauded NIH’s efforts to promote data sharing. She stressed the importance of developing best practices for dealing with data reanalysis to ensure robustness and reproducibility, as researchers may not always be aware of potential concerns. Dr. Insel wondered whether this would be a role for scientific societies and journals. Although the Federal Government should not dictate how researchers analyze their data, it can suggest that they consult guidelines. The BRAIN Initiative’s Council has suggested investments in training researchers on advanced statistics and analytics. Gregory Simon, M.D., M.P.H., noted that there is a larger movement for science to share resources and overall management. In an approach with radical transparency, researchers have access to shared data but must also publically state their analysis plan and programming code.
Carol Tamminga, M.D., commended the BRAIN Initiative and asked how the field could have input. Dr. Insel responded that town hall meetings were held in four parts of the country during 2013. NIH invited scientists from many different disciplines and members of the general public to provide feedback. Brain 2025 incorporated that feedback. Although the clinical community was less involved than the engineering and neuroscience communities, the report contains some discussion of potential clinical applications.
Gene Robinson, Ph.D., remarked that it is great to see funding and infrastructure development for the BRAIN Initiative. He asked about milestones, which were helpful for the Human Genome Project, for the BRAIN Initiative. Dr. Insel responded the milestones were a requirement. At the moment, the BRAIN Initiative does not have specific deliverables. The work of the Human Genome Project was linear and relatively easy to implement, because the fundamental scientific questions were already answered; this is not the case with the human brain. The first milestone for the BRAIN Initiative (as discussed in Brain 2025) is to develop a “parts list” (i.e., identify cells and circuits). It is critical to involve new people from diverse backgrounds in this work. The value of involving people from other disciplines is shown by the CLARITY Project. Dr. Robinson said he was pleased to hear about work on circuits, but the term must be defined properly. We think of brain circuits as analogous to electronic circuits, but that is inaccurate. It is important to acknowledge that the field really does not know what a brain circuit is. Dr. Insel agreed that an appropriate metaphor is lacking. Although we often compare the brain to a computer, we do not really know whether the brain works like one or not.
Lisa Greenman, J.D., asked about support of mental health services in jails and prisons. Dr. Insel replied that NIMH is a research institution, and services fall under SAMHSA’s purview. However, NIMH does support research on mental health among criminal justice populations and is collaborating with the Department of Justice to examine mental health diagnostics and to improve measures of the extent of different mental illnesses in these settings. He asked the Director of SAMHSA’s Center for Mental Health Services (CMHS), Paolo del Vecchio, M.S.W., to comment on the agency’s efforts in this area. Mr. del Vecchio remarked that SAMHSA efforts focus on preventing people with mental illnesses from entering the criminal justice system through use of special courts, grants, and technical assistance to states.
Patricia Areán, Ph.D., noted the impressiveness of the RAISE project and efforts to scale up. She asked about NIMH’s future plans to collaborate for the scale-up of effective interventions. Dr. Insel responded that this is the way it could and should work. NIMH has collaborated with both SAMHSA and the Centers for Disease Control and Prevention, for example. The RAISE project has only shown feasibility, but outcomes should come soon. The process used for RAISE is a great model and serves as a reminder that when NIMH and Council consider concepts and the strategic plan, they should consider how other agencies (e.g., FDA and CMHS) will use the research. Dr. Areán remarked that given scale-up of the ACA, quality indicators and metrics for measuring fidelity to the psychosocial aspects of mental health interventions are important. NIMH’s Robert Heinssen, Ph.D., agreed and commented that an NIMH is working to address this issue (e.g., practical ways to assess fidelity, quality, and data collection procedures). The work will go online in FY2015, so now is a good time to add operational definitions for these strategies. Dr. Insel noted that this is part of building practice into research, as in the field of cardiovascular surgery, for example.
Speaking about the BRAIN Initiative, Steven Hyman, M.D., said that the joint council was a good step, but that it has come relatively late in the process. BRAIN-related efforts underway at the Defense Advanced Research Projects Agency are proceeding well and should be reported to NIH. Earlier coordination may help with persuading Congress. Dr. Insel commented that during its first year, BRAIN Initiative efforts moved very quickly, and he agreed that coordination could be improved moving forward. There will be more coordination for the next set of efforts. Gregory Farber, Ph.D., noted that people involved in the BRAIN Initiative have been working to improve coordination, with good discussions at the program level. NIH is working with the National Science Foundation on training.
David Brent, M.D., commented on the need to look outside the traditional psychiatric phenotypes to other types of disorders that commonly co-occur (e.g., migraine and anxiety or asthma and depression), because there is growing evidence of shared genes for these conditions. Dr. Insel expressed interest in the idea. Dr. Cuthbert responded that Dr. Brent’s point is a good one and aligns with established observations. Through the RDoC project, he hopes to expand outreach to other agencies to discuss this issue. Dr. Hyman added that genetics databases are not set up for researchers to look easily across diseases. However, findings of shared-risk genes will generate hypotheses and scientific productivity.
Comments from Retiring Council Members
Dr. Insel welcomed the remarks and observations of those who are attending their final meeting as Council members today.
Virginia Trotter Betts, M.S.N, J.D., remarked that she has had a ‘head-turning experience’ as a Council member. As a former Commissioner at the Department of Mental Health and Developmental Disabilities in Tennessee, and with no scientific training, she felt she had to work hard to keep up. However, she also felt that it is important for NAMHC to include members with the perspective of the mental health field. Clinicians never see a patient with only one problem, and they need guidance and information on appropriate interventions. Unfortunately, most people do not get into care, which is a serious problem that affects families, communities, and the entire country. It is important for NAMHC members to keep this in mind. When considering promising practices, members should ask when the information will be released to the field and the best ways to make practitioners aware of it.
Ms. Trotter Betts was looking forward to hearing about the NIMH Strategic Plan and discussions of the Institute’s public health mission. The public health perspective raises the question of the impact of NIMH programs. She said the collaborations between NIMH and SAMHSA are exciting. NIMH should look for gaps and new potential partnerships that will have an impact on public health. She remarked that in a recent meeting on implementing the ACA and opportunities to improve health, participants did not mention mental health, despite the high morbidity and mortality associated with mental illness. Ms. Trotter Betts appreciated the warm greeting when she joined Council, and thanked the Council for the opportunity to serve.
Dr. Simon commented that as a Council member, he learned a great deal about program staff at NIMH and was very impressed by their knowledge and dedication. As a general rule, we should understand everything we think we know will be proven wrong or incomplete eventually. This is good news, because it suggests that interventions will be much better when we gain better knowledge. When the way that we organize and fund research is more efficient, knowledge will progress more quickly. Dr. Simon thanked everyone for the opportunity to be part of the Council.
Draft NIMH Strategic Plan
Dr. Insel noted that the Council discussed the NIMH Strategic Plan during its May meeting, as it was time to update the 2008 document. Kevin Quinn, Ph.D., and Brent Miller, Ph.D., of the NIMH Office of Science Policy, Planning, and Communications (OSPPC), organized the development of the revised 2015 Strategic Plan. The draft 2015 Strategic Plan retains similar overarching concepts as the 2008 plan, but significant improvements and updates were incorporated at the level of individual strategies. The present goal was to have a conversation with Council members to get further comments and suggestions.
The “Introduction” section describes NIMH’s mission, vision, and overall funding strategy moving forward. The funding strategy is based on the Institute’s four Strategic Objectives, which form a foundation for activities for the next five years: (1) define the biological basis of complex behaviors; (2) chart mental illness trajectories to determine when, where, and how to intervene; (3) develop better preventive and therapeutic interventions; and, (4) strengthen the public health impact of NIMH-supported research. The challenge will be for the Institute to find the right balance between the four Strategic Objectives to achieve the greatest impact on public health. Regarding NIMH’s overall funding strategy, some areas (e.g., “-omics” areas) will be investigator-initiated, but other topics will be driven by collaborations with partners. Such collaborations will be targeted with clear deliverables, so NIMH will more often use cooperative agreements and contracts to have an impact and change specific aspects of the public health delivery system.
The Strategic Plan’s introduction has two sections, the “Adapting to a Changing Ecosystem” section and a “Cross-cutting Research Themes” section. The plan’s “Adapting to a Changing Ecosystem” section discusses the context and rationale for why NIMH has chosen this particular path. Relevant factors include: the increasing public health burden of mental disorders, the BRAIN Initiative, the changing mental health care landscape, new technologies, comparative effectiveness research, new sources of research support and collaboration, and citizen-centered science. The next section lays out the cross-cutting research themes for NIMH activities, including: transforming diagnostics, accelerating therapeutics, digital enterprise, preemptive medicine, global mental health, mental health disparities, partnerships, and investing in the future. The cross-cutting research themes represent critical concepts that resonate across every Strategic Objective. Of note, NIMH’s strategy for mitigating disparities appeared in the 2008 plan under “Public Health Approaches.” In the revised draft Strategic Plan, mental health disparities research is called out as a cross-cutting theme.
The next steps are to discuss the draft plan with NAMHC members, consider and incorporate Council and NIMH staff feedback, solicit public comment via the Federal Register for a 30-day period, analyze and incorporate public feedback, and publish the final document by January 2015. The Council should have the final Strategic Plan by its next meeting.
Dr. Insel briefly reviewed feedback Council members had submitted prior to the meeting. He encouraged more discussion, particularly about omissions and deletions in the draft plan. Dr. Quinn noted that the Strategic Plan is a top-level document that conveys the Institute’s vision. More specific information is conveyed in the structure of program implementation, through the Strategic Research Priorities found on the NIMH website and funding opportunity announcements for each Division, which align with NIMH’s Strategic Objectives.
Dr. Areán suggested a revision of the schematic in the Introduction section, as it may give the false impression that there is a shrinking set of investments associated with Strategic Objectives 3 and 4. The text in this section could use more explanation to help the field understand that this is not the case.
Mary Jane Rotheram, Ph.D., commented that the development of strategic plans usually involves investigators, whereas this process has not. This plan appears to describe a major realignment in the portfolio and funding mechanisms, with Strategic Objectives 3 and 4 driven by the Institute, and Strategic Objectives 1 and 2 driven by investigators. Dr. Insel responded that NIH’s general approach to developing strategic plans is variable, with some institutes developing provocative questions or bold ideas to guide their efforts. NIMH staff members debated this approach, because some believe that strategic plans are not amenable to scientific discovery (too much is unknown). However, Council and NIMH leadership decided that the 2008 Strategic Plan was useful and was based on a great deal of outside input, although it needed to be updated. NIMH staff members have already incorporated Council comments and have implemented many of the changes described in the revised plan. Regarding the more directive nature of Strategic Objectives 3 and 4, that type of science has a different quality and responds to a distinct need. Frankly, we have failed to bend the curve on those Strategic Objectives. Therefore, NIMH must lead in a different way to achieve translation and improve public health in concrete ways (e.g., reduce suicide rates). Under the investigator-initiated model, researchers have sent in their best ideas in those areas, yet improvement hasn’t been as rapid as the public needs.
Dr. Linehan commented on the lack of competent care (both behavioral and medication strategies) despite the availability of treatments, and on the lack of progress on improving mental health issues (e.g., suicide). A key issue is that there is no requirement for competence on the delivery of treatment. She remarked on the need to guide and support practitioners in the appropriate delivery of behavioral interventions. Sometimes, practitioners say they are providing behavioral interventions, but there are no requirements for training in the particular intervention or monitoring for fidelity or patient outcomes. Polypharmacy is another issue that needs more study. Researchers have generated knowledge about treatments, but competent delivery of these therapies relates to outcomes; this is an area that requires examination.
Dr. Wang stressed that the issues of practitioner competence, clear descriptions of the service provided, and the appropriateness of services are coming to the forefront with implementation of the ACA. The Institute of Medicine’s (IOM) Forum on Neuroscience and Nervous System Disorders has sponsored a fast-track study on these issues, which should yield concrete recommendations (e.g., serviceable metrics for showing treatment progress and checking whether people are receiving appropriate interventions). Their report is due January 30, 2015. Dr. Areán is involved in this effort. Although Dr. Areán could not comment at this time, she said the intent is for the report’s recommendations to stimulate research on better metrics and methods, including possible technology solutions. Dr. Insel noted that a recent paper by Dr. Hyman also addresses the gap between available treatments and policies that affect receipt of them (“The unconscionable gap between what we know and what we do,” Science and Translational Medicine, September 10, 2014).
Dr. Hyman said that in his experience, there are many meetings on mental health. Policymakers and systems should be the subject of study. The upcoming IOM study can have an impact because insurers will look at it. The mental health field needs biomarkers to enable objective measurements and outcomes for health care systems.
Hyong Un, M.D., commented that in the absence of data, people will use a common-sense mechanism of finance, which may or may not work. Biomarkers are tremendously important, because insurers need to be able to measure outcomes. The dissemination strategy must be rigorous. There are questions about the level of fidelity needed as well as the type of setting for mental health interventions.
Speaking about Strategic Objective 4, Dr. Simon expressed concern over broadcasting the view that there has been “no progress;” to repeat that statement is in itself a barrier to progress. This view discourages areas where there has been progress and encourages areas with no progress to hide. For each Strategic Objective, there should be an examination of the specific areas where there has been no progress and determine solutions.
Hakon Heimer, M.S., suggested that the Strategic Plan present the Strategic Objectives in reverse order (starting with the schematic in the introduction). Dr. Rotheram agreed with this suggestion.
David Sweatt, Ph.D., recommended that NIMH examine content in the Strategic Plan that may already be obsolete. For example, it seems that the terminology for some disorders may be obsolete. The language in the plan does not necessarily have to change, but the document should perhaps acknowledge that terminology is evolving and may be quite different five years from now.
Dr. Rotheram observed that the terms “social” or “emotional” are not used in the Strategic Plan and that the document only discusses pathology at the individual level, which is not consistent with data. She suggested that NIMH consider its funding mechanisms and whether they encourage cooperation and are efficient. NIMH program staff members might have input on the most efficient funding mechanisms. To her knowledge, NIH has not published data on this topic.
Dr. Barch also remarked on the Strategic Plan’s focus on the individual, despite the known impact of the environment on biology. The current draft does not address environmental influences, and its omission could have an impact on how researchers prepare their grant applications. Dr. Insel responded that NIMH staff members thought the report was explicit about environmental influences, but they will endeavor to clarify that language. Dr. Simon noted that this topic belongs in the section discussing developmental trajectories. The document should be more specific about interventions and the environmental and individual characteristics that influence their effectiveness. Dr. Hyman agreed with Dr. Barch that people will read the Strategic Plan for guidance and that it would influence their behavior. Dr. Hyman suggested a glossary or brief text boxes that explain particular terms and concepts.
Ms. Greenman stressed that the document should include a discussion about the impacts of race, ethnicity, and poverty (e.g., outcomes for transitioning youth influenced by race and ethnicity). Dr. Insel commented that historically, NIMH had aimed to fix poverty and injustice. During the past 18 years, the Institute has set a different course. Although NIMH acknowledges that these are challenges and that these factors affect mental illness, solving poverty does not fall under NIMH purview. Ms. Greenman referred to research indicating that the course of mental illness is influenced by environmental factors (e.g., poverty and violence exposure). Dr. Insel agreed, adding that other studies on broad interventions address environmental factors (e.g., the home nurse visiting program). Despite these very compelling data of positive generational and multigenerational effects, these programs have not been widely implemented.
John Davison, Ph.D., M.B.A., suggested minimizing the perceived dichotomy between NIMH and the American Psychiatric Association, and stated that the suggestion to reverse the order of the Strategic Objectives in the schematic may help. The plan is great. In addition to practitioner competence, it is important to consider access to care. For example, for the Department of Defense’s TRICARE system, Congress has mandated changing the provider benefit for licensed mental health counselors. However, there are issues with training and accreditation, so TRICARE has many mental health counselors who will continue working under physician referral and supervision. There is a great need for mental health care. Dr. Davison agreed with others who have spoken about the need to raise the competence of the entire field.
Dr. Sweatt noted that only a minority (15 percent according to a report on National Public Radio) of postdoctoral fellows will obtain a faculty position. The NIMH Strategic Plan should include language that encourages young people in research training.
Mr. Heimer added that a blueprint for science communication does not appear in the Strategic Plan. He asked: Is there a separate NIMH communication plan? What is the status of the Institute’s search for a Communications Director? Dr. Quinn noted that Alissa Gallagher, M.P.H., has been selected as the new chief of the Science Writing and Press Branch (i.e., communications) in OSPPC. The Institute considered including communications as part of its overall Strategic Plan, but instead decided to launch a separate Communications Strategic Plan in parallel. Dr. Insel noted that perhaps the communications Strategic Plan could mention that communication on the science of mental health links to other issues (e.g., fidelity to interventions, competence, and rigor). Dr. Linehan noted that one communication issue is the public perception that people are not mentally ill, but “good” or “bad,” and can change if they want to. However, people may be persuaded about the reality of mental illness if they see demonstrations of brain-behavior changes. She suggested funding tests of behavioral interventions that simultaneously examine changes to the brain. Such research could guide future therapy development. The Strategic Plan should include this topic in the discussion of biomarkers, as it is a very active area of research for NIMH investigators.
Dr. Tamminga recommended creating a bold Strategic Plan to drive cures and interventions. She stressed that the language should be bold; it is in some places, but needs to be throughout the document.
Dr. Barch commented on the need for data on the impact of environmental factors early in life (e.g., poverty) on the brain—particularly how these experiences may have long-lasting effects and prevent subsequent interventions from working. It seems that the most effective treatment is societal change, although many attribute problems to individual faults rather than structural issues. Dr. Insel commented that NIMH supports work on how race, ethnicity, socioeconomic status, and gender influence disorders (i.e., are mechanisms of disorder), even if they are not the target of therapeutic intervention. Dr. Areán remarked that cognitive training and exercises have shown promise at helping children who have experienced trauma. Such interventions may address the negative impact of environmental disadvantage.
Dr. Insel thanked Council members for a spectacular conversation. The draft Strategic Plan continues to evolve. Dr. Quinn added that the comments were useful, particularly to help avoid misinterpretation of the schematic presented early in the document.
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James Churchill, Ph.D., Office of the Director
Michael Schoenbaum, Ph.D., Office of Science Policy, Planning, and Communications
The Army Study to Assess Risk and Resilience among Servicemembers (Army STARRS) is a novel partnership between the Army and NIMH. Dr. James Churchill noted that work for Army STARRS has been conducted under a cooperative agreement, which can be both challenging and rewarding. As background, Dr. Churchill explained that the project goal is to identify risk and protective factors for suicide and psychological health among Soldiers. Data from the project will inform the development of evidence-based interventions, and the overall objective is to deliver actionable findings. Army STARRS components include: studies on historical administrative data, new Soldiers, the entire Army, pre/post deployment, in theater, and Soldier health outcomes. These studies involve a tremendous amount of data and many Soldiers. There is an opportunity to contact participants for follow-up in the future. In cases of suicide, the project has conducted retrospective in-depth interviews with surviving family members to try and understand the underlying reasons and how Soldiers who die by suicide differ from those who do not.
Dr. Michael Schoenbaum showed the past 12-month suicide rate for active Army Servicemembers and matched civilians over time. Matching is important, because 85 percent of soldiers are male and young. In 2004, the suicide rate for active Army members was half that for age- and sex-matched civilians. However, the Army rate doubled from 2004 to 2008, when the two rates became approximately equal. As of 2009, the Army rate exceeded that of the civilian population and has continued to do so, according to available data. By 2013, the Army rate had tripled relative to 2004 rates. However, in 2013, Army rates started to decline. Data from 2014 for both civilians and members of the Army are not yet available to determine whether this trend has continued.
The initial lessons learned from Army STARRS include evidence that challenges conventional wisdom about suicide among members of the Army. Data have dispelled a number of myths and show that instinctual, easy answers are often wrong. Using administrative data from Active Duty Soldiers from 2004-2009, the study dispelled the notion that relaxation of accession waivers was the cause of the climb in suicide rate in the Army: rates for Soldiers who entered with an accession waiver were not different from the rate for the rest of the Army. Likewise, serving under a stop-loss order, in which a Soldier is compelled to stay in the Army beyond term because of Army need, also is not sufficient to explain the increased suicide rates during this period. Although Soldiers used to live in communal barracks, approximately 15 years ago Congress mandated that the services shift to individual housing. Some thought that single housing might influence suicide rates, but Army STARRS data show that it is not related. A common idea is that multiple deployments are associated with the increase in suicides. There have been more multiple deployments since September 11, 2001. Typically in the current era, the first deployment occurs during the first 4 or 5 years of Army service. Army STARRS data show that this first deployment is associated with a significant and persistent elevated suicide rate relative to that of Soldiers who have never deployed. However, for those who remain in the Army and are redeployed, the second deployment does not increase the risk for suicide beyond what was associated with the first deployment. Additional deployment is stressful, of course, but the data indicate that second or third deployments are not driving the increase in suicide among members of the Army.
Army STARRS data has also identified areas of suicide risk. Although the finding was neither novel nor unexpected, Soldiers with identified behavioral health problems are at higher risk for suicide. Other risk areas include a lagging promotion schedule, military occupation, deployment early in Army career, and being at a transition point; the predictors for accident mortality and suicide are strikingly similar. The data reveal more details (e.g., timing) about suicide. Project staff members are using advanced algorithms developed from the data to help the Army identify which groups of Soldiers have significantly elevated predicted risk, and when suicides are most likely to occur. By way of a proof of concept, if one were to focus intervention efforts on an identifiable group of Soldiers with significantly elevated predicted suicide risk, a 20 percent reduction in suicides for the Army could be possible. The project has delivered algorithms for particular subpopulations and is working with the Army to validate and update them. Next steps include combining primary and administrative data to predict the risk for adverse outcomes during the first year of Army service. Army STARRS will also examine additional subgroups of interest and their outcomes.
Dr. Churchill commented that the team will continue its ongoing partnership with the Army on the translation of Army STARRS findings during the next five years. Collaboration with the Department of Defense and Army will focus on future research using the Army STARRS platform. The Framingham Heart study remains the conceptual inspiration for Army STARRS, as it is a model of rigorous longitudinal research with opportunities for novel directions.
Dr. Davison noted that it is good to see initial results, although validation is needed. Army STARRS is a tremendous study that will yield robust data extending beyond the military population. As the project identified behavioral health issues as risk factors, the Army has changed its system of behavioral care during the past two years (e.g., clinic structure, standard policies, and implementation of step-down care for both inpatients and outpatients). The Army has rolled out a data portal so that standard mental health symptoms are assessed at every visit. It is worth studying the effects of the Army changing its behavioral health system.
Dr. Simon applauded progress in this area of research and stressed the need for more information on the timing of suicides. The Army STARRS dataset is uniquely rich with information that is not available in any other population and has great potential to help elucidate many aspects of suicide, including timing.
Ira Katz, M.D., Ph.D., of the Department of Veterans Affairs (VA) expressed gratitude to members of the Army STARRS project for applying the lessons learned to their collaborative work with the VA. In this work, the VA is taking a similar approach to risk stratification using information from electronic health records. This approach has been effective at identifying risk strata and concentrations of individuals at risk. However, effective risk stratification raises the question of how to act on this information. Intervening with individuals among the highest risk group does not change the overall rate of suicide, because most suicides occur among those outside this group. The next step is to develop clinical interventions for people who have the highest risk as well as others in the intermediate risk group.
Dr. Rotheram asked whether other investigators can access Army STARRS data. Dr. Schoenbaum responded that the project encourages other researchers to examine Army STARRS data and is moving forward on a plan to make the data accessible.
Dr. Insel thanked Drs. Churchill and Schoenbaum and noted that the value of Army STARRS will likely accrue over decades. He also thanked the project’s investigators and the Henry M. Jackson Foundation, which provides a home for this massive effort.
Dr. Tamminga noted that a decade ago, she was on an IOM committee that examined the health of soldiers. Researchers knew very little at that time, and it is gratifying to see progress from this great effort. Dr. Insel added that Army STARRS melded 38 separate databases, which was an enormous and very important task that took a couple of years to complete.
Dr. Insel opened the session by stating that the concepts are developed in response to scientific needs identified by researchers, Council members, NIMH, NIH, HHS, or the White House. They are open for discussion and contingent on available funding. Dr. Insel reminded Council members and members of the public that the cleared Concepts will be posted on the NIMH Web site and there will be opportunity for additional comment through those Web pages.
Adaptation/Optimization of Technology (ADOPTech) to Support Social Functioning
Lisa Gilotty, Ph.D., Division of Developmental Translational Research
Social deficits are common among people with mental illness, and these problems can be intractable to traditional interventions. Dramatic developments in innovative, state-of-the-art technologies (e.g., biosensors, virtual reality, and Google Glass) offer new possibilities for creative approaches to intervention. Many of these tools are used to address some components of mental disorders, but there is a gap in addressing social deficits. A problem is the lack of a bridge between innovative tools and clinical uses in an academic setting. There are few investigators with treatment expertise to collaborate with device developers to focus on testing new technologies for therapeutic applications.
Dr. Lisa Gilotty described the goal of ADOPTech as promoting catalytic partnerships between treatment researchers and engineers, computer scientists, and others for the development of social prosthetic technologies. These tools will be designed to enhance functioning to meet the needs of individuals with social impairments. The technologies will target skills that have a meaningful impact on quality of life. The expected outcomes include novel technologies (e.g., adapting hologram technology for real-time coaching or an artificial-intelligence application that works with a robotics platform) that target social functioning. For this concept, NIMH will look for ground-breaking technologies to augment existing, established interventions focused on social functioning.
Dr. Barch wondered why the concept focuses on social functioning. Dr. Gilotty noted that social impairments overlap with other functional domains and exacerbate difficulties. Also, traditional interventions do not improve social functioning, so this is a gap area.
Dr. Simon emphasized that discoveries under this concept should focus on a fundamental idea about stimulating the brain rather than a particular device or delivery platform, as these quickly become obsolete. Other Council members liked the concept and reiterated the importance of not tying interventions to particular technologies.
Lifespan Human Connectome Project (HCP): Children and Adolescents
Stacia Friedman-Hill, Ph.D., Division of Developmental Translational Research
Concept Developed by the Lifespan HCP Working Group, NIH Blueprint for Neuroscience
The NIH Blueprint for Neuroscience Research is currently funding the Human Connectome Project (HCP), via a cooperative agreement, to collect and share structural and functional connectivity data from a large sample of healthy adults, age 22-35. Dr. Stacia Friedman-Hill described the goal of the present initiative as extending the experimental protocols developed through the HCP to children and adolescents, to investigate the structural and functional changes that occur in the brain during typical development. Expansion of the HCP has the potential to significantly enhance the clinical relevance of the data and provide developmental benchmarks for understanding pathological processes in the etiology of human brain disorders.
Over the course of the last decade, there has been an explosion of interest in the patterns of connectivity underlying structural and functional brain networks. Whereas older theories of brain disorders focused on single brain regions, the recent shift to studying connectivity and networks is revolutionizing how we understand neurological, mental, and developmental disorders, as well as age-related disorders and substance abuse. To date, HCP teams have developed and optimized non-invasive imaging technologies to acquire high resolution structural and functional in vivo data about axonal projections and neural connections from brains of hundreds of healthy adults. Demographic, sensory, motor, cognitive, emotional, and social function data have also been collected for each participant. The data and experimental protocols have been made available to the research community, and are now being used widely.
While the HCP launched the field of human connectomics and is providing the first well-characterized, quantitative datasets of human connectivity linked to genetic and behavioral data, the HCP is limited to the young adult brain—a very small portion of the overall human lifespan. Enormous structural and functional changes occur in the brain during typical development and aging. A complementary extension of the HCP to capture trajectories of maturation of structural and functional connectivity would greatly enhance the utility of this dataset and provide valuable reference data to support research examining the role of neurodevelopment in a variety of brain-based disorders.
The expected outcome of the HCP for children and adolescents is a state-of-the-art, high-resolution structural and functional reference atlas for the developing human brain. This project offers many advantages, including maximum compatibility with existing HCP imaging, behavioral, and genetic protocols (with modifications to accommodate technical challenges in children and adolescents). The project is informed by data from lifespan pilot studies and Washington University and the University of Minnesota and Massachusetts General Hospital. Other advantages include a design that is both cross-sectional and longitudinal, use of multimodal neuroimaging, and a timeframe that spans early childhood to age 21 as well as the end goal of making the full dataset available to the public within five years.
Maria Oquendo, M.D., commented that the project is an exciting opportunity. A challenge is to also have excellent longitudinal clinical phenotypes. Dr. Robinson wondered whether the concept was too narrow, as there are other developmental neuroimaging initiatives. He asked whether the Institute had considered reworking the existing programs to expand them for technical aspects and to include the target group. He also inquired about working with the European program, which has some research linkages with the United States. Dr. Friedman-Hill replied that the HCP for children and adolescents is significantly different from other ongoing studies, some of which are near completion. The ground is always shifting with neuroimaging technologies—the state-of-the-art technology is likely to change in the next five years—and it is difficult for projects to change hardware midstream. NIMH is open to working with European colleagues. Dr. Casey added that this project will assist many researchers who want to conduct developmental studies. It is good for advancing the NIMH Strategic Plan as well as the NIH Blueprint for Neuroscience Research.
Going to Scale with Mental Health Innovations to Reduce the Treatment Gap in Low- and Middle-Income Countries
Beverly Pringle, Ph.D., Office for Research on Disparities & Global Mental Health
This initiative would stimulate collaborative research on scaling up delivery of science-based mental health interventions in low- and middle-income countries (LMICs), and enhance regional capacity to conduct mental health research. More than 80 percent of the world’s population lives in LMICs. The burden of disease associated with mental disorders is rising in these countries. On average, there is a 200-fold difference in investments in mental health care between low- and high-income countries. These situational factors require innovative solutions for scaling up evidence-based care in LMICs.
Recent advances in mental health policies, research, and service delivery in LMICs have set the stage for new investments aimed at scaling up innovations to reduce the mental health treatment gap in these countries. These advances are extending our understanding of elements that contribute to successful mental health care systems in LMICs and will inform efforts to scale up services. The World Health Organization (WHO) and others are calling for scaling up mental health interventions, but there are many challenges (e.g., relatively low median mental health expenditures per capita and a low number of mental health providers).
This problem requires new solutions rather than a simple transfer of interventions used in high-income countries. Some partial solutions have been reported: WHO Mental Health Global Action Programme, 2010; a CBT-based intervention by community health workers for mothers with depression and their infants in rural Pakistan (PMID: 18790313); home care for supporting caregivers of people with dementia in India (PMID: 18523642); group interpersonal psychotherapy for depression in rural Uganda (PMID: 12813117); and, community-based rehabilitation for people with psychotic disorders in rural India (PMID: 19880934). The interventions used in these studies involved task sharing, with delivery by community health workers under the supervision of mental health specialists. Researchers consistently find that community health workers can be trained to deliver mental health interventions for people with depression, anxiety, schizophrenia, and dementia in a diverse range of LMICs.
For this NIMH concept, the goals are to: (1) support implementation research on models to scale up delivery of effective mental health care in resource-poor settings and (2) enhance regional capacity in LMICs to conduct research that can improve mental health care and outcomes. There are opportunities to leverage the investments of these countries and other organizations. NIMH would like feedback from Council members on the Institute’s role and how it can contribute to filling the knowledge gap.
Dr. Tamminga mentioned a prevention intervention used in very a poor Native American community that dramatically improved outcomes for the infants of young mothers (12 to 19 years old). The intervention program hired and trained indigenous grandmothers from the tribe to teach parenting skills to the young mothers. Children’s outcomes at 2 years were much better than the comparison group. Dr. Tamminga suggested that, perhaps, similar interventions could be implemented in LMICs.
Ms. Trotter Betts observed that this is a great opportunity to describe what we know and identify the interventions that work best in communities with poor resources (along with the range of fidelity for effectiveness). The positive intergenerational effects of home visits to high-risk families by public health nurses are well known. Many foundations would have an interest in these models and in implementing them widely. She also mentioned the important role that general nurses trained for mental health work can play in improving access. If there is success implementing that model globally, then perhaps disadvantaged communities in the United States might use it. Mental health professionals are not dispersed equally around the United States, and some communities have very few providers.
Dr. Linehan noted the good work treating severe PTSD in other counties. She recommended transporting effective interventions for low-resource settings to the United States. Specifically, the United States should try to use some of the models of delivery from these countries. For example, interventions implemented by providers who are not trained in mental health but received training in those particular interventions (with the oversight of specialists) have shown good outcomes. There is no reason to believe that having a professional degree leads to better outcomes. Rather, what seems to matter is whether the provider received training in the particular intervention. More research is needed on this model in the United States.
Dr. Rotheram strongly endorsed models in which generalists trained in a specific mental health intervention play a key role. General interventions are important too. For example, researchers in South Africa have demonstrated that during the first 1,000 days of life, interventions that address general health issues (e.g., HIV, malnutrition, and alcohol use) can have a salutary effect on mothers’ depression.
Dr. Areán asked whether researchers could conduct similar efforts involving home-grown, generalist providers simultaneously, both in international settings and in the United States. Additionally, technology can deliver critical educational lessons. For example, people in the communities can learn how to clean their water and avoid dysentery via computer tablet-based lessons from health workers. Dr. Oquendo endorsed the idea of conducting research in tandem. Regarding the discussion on delivery of care by generalists trained in a particular intervention, a potential point of resistance might be the question of whether it is ethical to provide a different kind of treatment to an underprivileged population.
Dr. Insel invited members of the audience to make any comments to Council. Hearing none, he thanked all who participated in the meeting. He recessed the open session at approximately 12:30 p.m.
Summary of Primary MH Applications Reviewed
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Department of Health and Human Services
National Institutes of Health
National Institute of Mental Health
National Advisory Mental Health Council
(Terms end 9/30 of designated year)
- Thomas R. Insel, M.D.
National Institute of Mental Health
- Jane A. Steinberg, Ph.D.
Division of Extramural Activities
National Institute of Mental Health
- Patricia A. Areán, Ph.D. (16)
Department of Psychiatry and Langley Porter
University of California, San Francisco
San Francisco, CA
- Deanna M. Barch, Ph.D. (16)
Gregory B. Couch Professor of Psychiatry
Department of Psychology, Psychiatry and Radiology
St. Louis, MO
- Virginia Trotter Betts, M.S.N, J.D. (14)
Professor of Nursing and Public Policy
University of Tennessee Health Science Center
College of Nursing
- David A. Brent, M.D. (17)
Child & Adolescent Psychiatry
Endowed Chair in Suicide Studies
Professor of Psychiatry, Pediatrics and Epidemiology
Director, Services for Teens at Risk
University of Pittsburgh School of Medicine
- Randall L. Carpenter, M.D. (15)
Co-Founder, President and Chief Executive Officer
- BJ Casey, Ph.D. (16)
Department of Psychiatry and Neuroscience
Sackler Institute for Developmental Psychobiology
Weill Medical College of Cornell University
New York, NY
- Lisa Greenman, J.D. (15)
Federal Public Defender
- Hakon Heimer, M.S. (16)
Schizophrenia Research Forum
Brain and Behavior Research Foundation
- Richard L. Huganir, Ph.D. (17)
Professor and Director
Department of Neuroscience
Investigator, Howard Hughes Medical Institute
Co-Director, Brain Science Institute
The Johns Hopkins University School of Medicine
- Steven E. Hyman, M.D. (15)
Director, Stanley Center for Psychiatric Research
- Marsha M. Linehan, Ph.D. (17)
Professor and Director
Behavioral Research and Therapy Clinics
Department of Psychology
University of Washington
- Maria A. Oquendo, M.D. (17)
Vice Chair for Education
Professor of Clinical Psychiatry
Department of Psychiatry
New York State Psychiatric Institute
New York, NY
- Gene E. Robinson, Ph.D. (16)
Director, Institute for Genomic Biology
Center for Advanced Study Professor in Entomology
University of Illinois at Urbana-Champaign
- Mary Jane Rotheram, Ph.D. (16)
Bat-Yaacov Professor of Child Psychiatry
And Behavioral Sciences
Director, Global Center for Children and Families
Director, Center for HIV Identification Prevention
And Treatment Services (CHIPTS)
Semel Institute and the Department of Psychiatry, University of California, Los Angeles
Los Angeles, CA
- Gregory E. Simon, M.P.H., M.D. (14)
Senior Scientific Investigator
Center for Health Studies/Behavioral
Group Health Cooperative
- J. David Sweatt, Ph.D. (16)
Evelyn F. McKnight Endowed Chair
Department of Neurobiology
Director, McKnight Brain Institute
University of Alabama at Birmingham
- Carol A. Tamminga, M.D. (15)
Professor and Chair
Department of Psychiatry
University of Texas
Southwestern Medical Center
- Hyong Un, M.D. (17)
Head of EAP & Chief Psychiatric Officer
Blue Bell, PA
Ex Officio Members
Office of the Secretary, DHHS
- Sylvia M. Burwell
Department of Health and Human Services
National Institutes of Health
- Francis Collins, M.D., Ph.D.
National Institutes of Health
- Ira Katz, M.D., Ph.D.
Department of Veterans Affairs
Office of Mental Health Services
Department of Defense
- John W. Davison, M.B.A., Ph.D.
Chief, Conditioned-Based Specialty Care Section
Clinical Support Division
Defense Health Agency
Department of Defense
Office of the Chief Medical Officer (OCMO)
TRICARE Management Activity, OASD (HA)
Falls Church, VA
- Paolo del Vecchio, M.S.W.
Center for Mental Health Services