Challenges and Opportunities
The urgency of NIMH’s mission stems from the significant burden mental illnesses impose on individuals, their families, and society. In any given year, nearly one-fifth of all U.S. adults struggle with a mental illness1 and the burden of mental illness is predicted to rise worldwide in coming decades.2,3 Mental illnesses cut across age, gender, race, ethnicity, and socioeconomic status. Mental illnesses occur more commonly in people with other chronic illnesses, such as heart disease, diabetes, and HIV.4,5 Individuals with mental illnesses are disproportionately represented among the homeless and the incarcerated.6 Further, serious mental illnesses significantly impair one’s ability to function in daily life, are associated with personal loss of earnings,7 have a negative global financial impact,8 and are among the leading causes of poor health and early mortality worldwide.9,4 Tragically, suicide remains among the top 10 leading causes of death in the United States, and suicide rates have increased by more than 30 percent over the last two decades.10 Increases in the national suicide rate further underscore the public health burden of mental illnesses. The burden of mental illnesses demands that we harness scientific knowledge and tools to achieve better understanding, prevention, and treatment of these disabling conditions. In this section, we outline our plans to leverage considerable research opportunities to address the many challenges of mental health and mental health research.
Given the troubling rise in the national suicide rate in the past decades, suicide prevention research remains an urgent priority for NIMH. NIMH’s portfolio includes projects aimed at identifying individuals and populations most at risk for suicide, understanding the causes of suicide risk, developing suicide prevention interventions, and testing the effectiveness of these interventions and services in real-world settings. NIMH intramural and extramural research efforts have resulted in the development of screening tools for implementation in real-world settings to identify those at risk for suicide. Our current collaborative efforts are testing the benefits of risk detection and pragmatic interventions. Because many suicide decedents in the United States have accessed healthcare services in the 12 months preceding death, healthcare systems can play a vital role in identifying individuals at risk and preventing suicide attempts.11 NIMH research has focused on emergency departments as a critical focal point, demonstrating that brief screening tools can improve providers’ ability to identify individuals at risk for suicidal behavior.12,13 If instituted more broadly, research suggests screening could identify and refer to care more than 3 million additional adults at risk of suicide each year.14 Pairing this screening with a low-cost intervention, such as follow-up phone calls, results in significant decreases in subsequent suicide attempts in the following year.12 In addition, NIMH and extramural scientists’ collaboration on a mathematical modeling exercise demonstrates that mail-, phone-, and psychotherapy-based interventions could all be cost-effective if administered to patients identified as at-risk during emergency room visits.15 NIMH continues to support research to identify how and why these screening and follow-up interventions work, and how these evidence-based tools can be scaled up for broader implementation to prevent suicide attempts and deaths. In addition, accumulating evidence suggests that various preventive interventions delivered early in life can change children’s mental health and substance use trajectories in a positive manner, including decreased risk for suicidal ideation and behaviors in adolescence and adulthood.
Early Intervention in Psychosis
In 2008, NIMH launched the Recovery After an Initial Schizophrenia Episode (RAISE) project, a large-scale research initiative with the goal to help reduce the likelihood of long-term disability that people with schizophrenia often experience and help them lead productive, independent lives. A primary focus of the RAISE studies was to answer questions about the feasibility, effectiveness, and scalability of early intervention services for people experiencing first episode psychosis in the United States, with an emphasis on coordinated specialty care (CSC). Baseline findings from the RAISE studies documented areas in need of improvement, including the long duration of untreated psychosis,16 variable adherence to treatment guidelines,17 and poor attention to comorbid medical conditions.18 In addition, the RAISE studies demonstrated that early intervention improves clinical outcomes among youth with first episode psychosis, and that CSC is a feasible and cost-effective approach to early intervention in first episode psychosis.19,20,21 Through collaborations with other federal agencies, NIMH transformed these findings into real-world change. CSC is now the standard of care for early psychosis, with 285 CSC programs across the country.22 In 2018 alone, RAISE findings helped over 17,000 young people confronting the tremendous challenge of a first episode of psychosis by ensuring they had access to the best possible evidence-based care.
Going forward, NIMH is supporting an Early Psychosis Intervention Network (EPINET) to advance evidence-based treatment in first episode psychosis. The goal of EPINET is to create a “learning healthcare system” in which data that are routinely collected in CSC programs, as part of clinical practice, drive continuous improvement in client care and further scientific inquiry. Through EPINET, NIMH supports regional scientific hubs that will standardize, collect, and aggregate data across community clinics and use computational methods to study CSC fidelity, quality, and treatment effectiveness. By studying large, nationally representative data sets, EPINET may provide crucial insights into how to best tailor early psychosis care for individuals and provide information to guide improvements in diagnosis and intervention.
Mental Health Equity
Striking disparities exist in the prevalence and outcomes of mental illnesses within the United States and worldwide. Individuals from underserved communities frequently experience reduced access to evidence-based mental health services and lower levels of treatment engagement, and they receive fewer follow-ups in a variety of provider settings. In accordance with the 21st Century Cures Act, NIMH staff work closely with the National Institute on Minority Health and Health Disparities (NIMHD), the Office of Research on Women’s Health (ORWH), and other NIH Institutes, Centers, and Offices to ensure activities take into account the health needs of minorities and women and are focused on reducing health disparities. To achieve mental health equity, NIMH supports research that addresses the needs of individuals and communities across age, race, ethnicity, culture, language, gender identity, sexual orientation, geography, insurance status, socioeconomic status, and other social determinants of health. Further, to build a valid evidence base for effective prevention, treatment, and care, NIMH strives to foster an inclusive environment that values study participants and researchers from all backgrounds.
Around the world, the prevalence of mental illness is higher in people at risk for or living with HIV compared to the general population. Mental illness can be a barrier to engagement, linkage, and retention in the prevention and treatment of HIV and may lead to negative health outcomes such as poor medication adherence, higher HIV incidence rates, and increased disease burden. There are also many co-occurring biological, psychosocial, and structural factors, as well as social determinants such as stigma, violence, and stress that influence the development and course of mental illnesses and HIV. Mental health research is an integral component of HIV-related research across the lifespan and around the globe. As such, NIMH supports a broad research portfolio to prevent HIV acquisition and improve treatment and care among people living with HIV, including those with comorbid mental health and substance use disorders.
NIMH utilizes basic science to understand the pathogenic mechanisms of HIV-associated central nervous system (CNS) disorders, and to develop therapeutic strategies to treat HIV-CNS comorbidities, including cognitive disorders and mental illnesses. In addition, NIMH supports efforts focused on eradicating the virus from the CNS, a prerequisite to finding a safe, effective, and complete cure for HIV. To complement efforts in basic science, behavioral and social science research efforts examine environmental, group-level, individual, and interpersonal factors; peer and community-based strategies; as well as structural and psychosocial determinants that are critical in HIV prevention and treatment. NIMH supports implementation science that can enable researchers to bring evidence-based interventions to the greatest number of people who may benefit, particularly those who may be living with HIV in less resourced environments, both domestically and globally. NIMH also places a high priority on HIV research that can impact the most marginalized and underserved populations, including racial and ethnic minorities, sexual and gender minorities, adolescents, women and infants, and other marginalized groups across the lifespan.
Digital Health Technology
Recent advances in technology have continued to evolve and create new opportunities to improve access, availability, utilization, and quality of mental healthcare services. The growth of digital health technologies, which blend mobile health and health information technology (such as smartphones, wearable sensors, electronic health records, etc.), gives the public, healthcare providers, and researchers new ways to access information and to measure and manage health and productivity. Ongoing NIMH-supported research leverages mobile and other emerging technologies to develop, test, and deliver targeted prevention and treatment interventions. Approaches include just-in-time interventions that can be pushed out using smartphones or other technology based on information about the person’s current state and needs. Additional innovations employ patient- and clinician-facing digital monitoring devices, smartphones, and other applications or dashboards that facilitate monitoring and early detection of changes in patient status that might signal the need for additional or more intensive services to forestall relapse or hospitalizations. NIMH is also interested in digital technologies as biomarkers and clinical outcome assessments for inclusion in clinical trials for monitoring responses to interventions. While the technology frontier offers promising opportunities for mental health care, much work remains to address questions about efficacy and effectiveness, regulation, and privacy.
Tremendous progress has been made in psychiatric genetics. Genome-wide association studies (GWAS), which required global-scale collaborations to assemble immense sample sizes, uncovered statistically rigorous and fully-replicated genetic links to schizophrenia, autism, depression, and other psychiatric disorders. In considering the complexity of the genetic landscape, the Report of the National Advisory Mental Health Council Workgroup on Genomics provided recommendations for the future of genomics research: 1) utilize statistically rigorous, unbiased, and well-powered studies; 2) harness innovative approaches that address both common and rare genetic variants; and 3) leverage universal data sets that capture genetic and phenotypic variation across diverse human populations. NIMH is focused on expanding the ancestral diversity of genetic samples and increasing our understanding of the genetic determinants of mental illnesses, like obsessive-compulsive disorder, anorexia nervosa, and other disorders where progress has been slow. A significant goal is to better understand how molecular, neural, environmental, and psychosocial mechanisms interact with the genetic and epigenetic links that have been identified. Acquiring this new knowledge will likely cross levels of analysis, from genes to cells to circuits to behavior.
Neuroscience has provided us with the tools to look deeply into the function of neural circuits, and directly test hypotheses about brain-behavior relationships using noninvasive brain stimulation technologies. Over the past decade, technologies – such as optogenetics, chemogenetics, viral tracing, and high-resolution optical imaging – aimed at measuring and modulating the activity of specific circuits, have facilitated the attainment of a vast knowledge base about the circuits that control behavior and mental processes. Noninvasive neuromodulation devices allow scientists to change function within circuits for therapeutic benefit, and this approach led to the U.S. Food and Drug Administration (FDA) approval of transcranial magnetic stimulation (TMS) for the treatment of depression and obsessive-compulsive disorder. This knowledge, in turn, may enable the development of diagnostic and treatment strategies that detect and normalize circuit dysfunction in people with mental illnesses. In addition, invasive neural recording devices (e.g., deep brain stimulation with implanted electrodes) being used to treat a variety of clinical conditions in humans may enable researchers to explore neural circuity underlying complex human behavior and mental illnesses. To drive progress in circuit neuroscience, NIMH, in part through the NIH Brain Research Through Advancing Innovative Neurotechnologies® (BRAIN) Initiative, aims to reveal how complex neural circuits dynamically interact to influence mental functions. NIMH is committed to understanding which circuits are altered in mental illnesses and how; which circuit elements can be changed to reverse or compensate for these alterations; and, at which points in time during the course of illness these manipulations are most effective.