The National Institute of Mental Health (NIMH) is the lead Federal agency for research on mental illnesses. The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure.
The urgency of this mission arises from the public health burden. According to recent estimates, mental illnesses account for 21.3 percent of all years lived with disability in the United States.1 An estimated 9.6 million American adults suffer from a serious mental illness (SMI) in which the ability to function in daily life is significantly impaired. Those with SMI die 10 years earlier than individuals in the general population, on average.2 Furthermore, over 41,149 Americans die each year from suicide, more than twice the annual mortality from homicide or AIDS.3 Beyond the morbidity and mortality, a conservative estimate places the direct and indirect financial costs associated with mental illnesses in the United States at well over $300 billion annually.4 Mental illnesses rank as the third most costly medical conditions in terms of overall health care expenditure, behind heart conditions and traumatic injury.5
This public health burden demands that we harness scientific knowledge and tools to achieve better understanding, treatment, and ultimately, prevention of these disabling conditions. We must do better. To fulfill its mission, the NIMH:
- Supports and conducts research on mental illnesses and the underlying basic science of brain and behavior.
- Supports the training of scientists to carry out basic and clinical mental health research.
- Communicates with scientists, patients, providers, and the general public about the science of mental illnesses.
Fundamental to our mission is the proposition that mental illnesses are brain disorders expressed as complex cognitive, emotional, and social behavioral syndromes. Progress depends on advances in basic behavioral science and fundamental neuroscience, in addition to clinical science.
In 2008, the NIMH published a Strategic Plan to accelerate progress in both basic and clinical science. This Plan was limited to research, with separate planning efforts for training and communication. With the remarkable growth in scientific findings during the past 6 years, and the changing landscape of mental health care, the need to update the Plan became clear. Several other strategic plans have informed our planning and include more detail on specific topics, such as the National Research Action Plan (NRAP) addressing post-traumatic stress; the Interagency Autism Coordinating Committee (IACC) Strategic Plan for Autism Spectrum Disorder Research; A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives, a collaboration with the the National Action Alliance for Suicide Prevention; and the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Working Group Report. NIMH also has a substantial investment in supporting AIDS research; it is important to note that this investment is guided by a National Institutes of Health (NIH)-wide Strategic Plan coordinated through the NIH Office of AIDS Research; as such, research on the mental health aspects of AIDS is not addressed in the current Plan.
In this new Strategic Plan for Research, with the goals of helping individuals living with mental illnesses and promoting both prevention and cure, NIMH has revised the original four, high-level Strategic Objectives (SOs) as follows:
- Define the mechanisms of complex behaviors.
- Chart mental illness trajectories to determine when, where, and how to intervene.
- Strive for prevention and cures.
- Strengthen the public health impact of NIMH-supported research.
These four Strategic Objectives form a broad roadmap for the Institute’s research priorities over the next 5 years, beginning with the fundamental science of the brain and behavior, and ending with public health impact. Our overall funding strategy is to support a broad spectrum of investigator-initiated research in fundamental science, with increasing use of Institute-solicited initiatives for applied research where public health impact is a short-term measure of success. Full implementation of these Strategies, will, we hope, transform the diagnosis, treatment, and prevention of these devastating illnesses.
Adapting to a Changing Ecosystem
The purpose of the NIMH Strategic Plan for Research is not only to convey the next steps on the path to realizing the Institute’s vision, but also to provide the context and rationale for why we have chosen this particular path. Good stewardship of public funds necessitates constant surveillance of the ecosystem within which the Institute functions and adaptation when the situation demands it. The field of mental health has witnessed substantial change and progress since 2008. This section highlights the major ways in which the ecosystem has changed and how the Institute is adapting.
The Increasing Public Health Burden
Mental illnesses remain an urgent public health issue. Media coverage of mass shootings, celebrity suicides, and the high rates of mental illness in prisons and among the homeless have increased the Nation’s attention on the need for better mental health care. With the increasing suicide rate in the military, as well as hundreds of thousands of service members returning with post-traumatic stress disorder (PTSD), traumatic brain injury, and depression, a White House Executive Order and members of Congress have called for an intensive response to the “invisible wounds” of war. The increasing prevalence of autism, which rose from 1 in 150 in 2008 to 1 in 68 in 2014, demands both research and expanded care. Together, these changes not only contribute to the increasing public health challenge, they also reveal the need for a deeper understanding of mental illnesses and their treatments.
The BRAIN Initiative
The BRAIN Initiative, announced by President Obama in April 2013 as the “next great American project,” is supporting the creation of new tools for decoding the language of the brain. This initiative, which NIMH co-leads with the National Institute of Neurological Disorders and Stroke, supports teams of engineers, nanoscientists, computational scientists, and neuroscientists to find new, efficient ways to monitor and manipulate brain circuits. The development of tools and technologies that will deepen our understanding of the brain’s structure and function will also give us new approaches to map aberrant brain activity associated with mental illnesses. We have already made considerable progress on this path, progress that surpasses our predictions from 6 years ago. For instance, the Human Connectome Project has given us unprecedented multimodal maps of the healthy human brain. With this technology, in the near future we expect maps of neurodevelopment in health and illness (see SO1 and SO2). The deeper understanding of the brain’s structure and function made possible by these new tools and techniques will lay the groundwork for better therapeutic and preventive interventions.
The Changing Mental Health Care Landscape
The implementation of the Patient Protection and Affordable Care Act of 2010 (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) forecasts vast changes in mental health care. The MHPAEA requires insurance groups that offer coverage for mental health care to provide the same level of benefits that they offer for general medical treatment; the ACA defines mental health care as an “essential benefit” and extends the public reach of the requirements of the MHPAEA. However, the implementation of these laws may only apply to treatments that can meet evidence-based standards. While many evidence-based treatments exist, we lack valid metrics for measuring the quality and efficacy of care. For clinicians and other decision makers, electronic health records, smart sensors, and novel forms of care delivery will provide opportunities to learn from individuals with mental illnesses, and to continually apply that knowledge to improve mental health care.
The priorities outlined in the later Objectives of the Strategic Plan for Research (SO3 and SO4) will inform how we address the demands that new policies such as the ACA and the MHPAEA bring. How will the increased demand for mental health care be met? How can we ensure that evidence-based practices are implemented across diverse settings for increasingly diverse populations? What are the best methods for transferring the latest knowledge and new interventions to the workforce? The answers to these questions will need to be addressed by NIMH in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), the U.S. Department of Veterans Affairs (VA), and others.
The rapidly evolving health technology sector has the potential to radically transform the way all people (i.e., patients, providers, researchers, payers) interact within the mental health care system. Mobile technologies are changing the world of mental health care in ways that could scarcely have been imagined before the social media revolution. This is evident in the use of mobile devices as sensors to detect subtle changes in activity, and by extension, emotional state; as online extenders of individual psychotherapy; or as tools to move evidence-based interventions into remote communities. New methods for investigating activity within brain circuits, such as functional magnetic resonance imaging (fMRI) neurofeedback, are already being tried as treatments. And noninvasive approaches to strengthening circuits, like cognitive training exercises—potentially offered through entertainment software and video game platforms—may open doors for researchers to build resilience and prevent mental illnesses from occurring, rather than simply reduce symptoms. The promise is enticing, but there are still many unanswered questions about effectiveness, concerns about privacy, and challenges for regulation of these nascent technologies.
In addition to developing new treatments, NIMH has pioneered the use of practical trials, comparing existing interventions to determine effectiveness in real-world settings. This information is critical for people with mental illness, providers, and policy makers. Such comparative effectiveness research (CER) can inform health care decisions by providing evidence of the effectiveness and/or possible harms of different treatment options. Fortunately, NIMH is no longer the only source of support for this class of large and costly practical trials. Over the past 6 years, the CER approach has gained broader support and substantial momentum. The congressionally authorized Patient-Centered Outcomes Research Institute (PCORI) funds a range of clinical effectiveness studies. The NIH Common Fund Health Care Systems Research Collaboratory project, co-led by NIMH, has supported CER trials in large health care delivery systems. The Center for Medicare and Medicaid Innovation, part of the Centers for Medicare and Medicaid Services, was established to answer practical questions about health care delivery, often via the support of CER-type trials. Further, the new NIH National Center for Advancing Translational Sciences has focused on CER across its 62 Clinical and Translational Science Centers. None of these various sources of support for CER, which in aggregate surpass a billion dollars per year, were present 6 years ago. This changes the NIMH role to partner rather than sole supporter of CER for mental health, with a responsibility for ensuring that these other sources of support include research on mental illnesses.
New Sources of Research Support and Collaboration
The structure and function of the brain in health and illness has become an area of high interest for private as well as public research investment. Private, nonprofit organizations such as the Stanley Medical Research Institute, the Simons Foundation, the Allen Institute for Brain Science, the Brain and Behavior Research Foundation, and the Kavli Foundation, to name just a few, have each developed unique approaches to contribute to understanding the brain and mental illnesses. Over the past 6 years, private support for mental health research has soared with the formation of new institutes and the creation of new funding sources. From the researcher’s perspective, science philanthropy provides almost 30 percent of the annual research funding in leading universities and has been growing at almost 5 percent annually.6 Internationally, there is also increased investment in brain and mental health research, although this tends to be with public rather than private funding. National brain research projects have been launched in the European Union, China, Japan, Australia, and Israel. With private funding and global support increasing over the past 6 years, NIMH can look to new partnerships for funding, potentially leveraging new privately funded research programs.
A final and relatively new form of collaboration—citizen-centered science—holds considerable promise for revolutionizing the way biomedical research is conducted. Citizen-centered science builds solutions for research problems on a culture of data sharing and crowd sourcing. Whether through challenges for solving basic science problems or by empowering patients in clinical trials, new models have emerged over the past 6 years. Promising models and solutions for these challenges are being actively pursued by new citizen-science research partners, such as the Genetic Alliance, Patients-Like-Me, 23andMe, and Sage Bionetworks.7
Cross-Cutting Research Themes
With the changing ecosystem for neuroscience and mental health research, each of the Strategic Objectives of the 2008 Plan has evolved. Along with the specific changes in research objectives, several cross-cutting themes have emerged that are relevant to each of the Objectives. This section summarizes the major themes that, along with the changing landscape, motivated this Strategic Plan for Research.
The Research Domain Criteria (RDoC) Initiative—which began as Strategy 1.4 within SO1 in the 2008 Strategic Plan—has grown into a significant cross-cutting effort for the Institute. In contrast to current symptom-based diagnostic systems for mental illnesses, RDoC integrates many levels of information (from genomics to social factors) for each patient to provide a precise characterization. RDoC frees clinical investigators from the current diagnostic categories and encourages basic scientists to identify molecular or neural mechanisms of specific domains of mental function, rather than creating models of diseases. Information from the RDoC project is now being aggregated into a common, comprehensive database—called RDoCdb—which will allow researchers to share and mine the results of NIMH-funded research.
New tools and discoveries from genomics, neuroscience, and cognitive science have led to new ideas about treatment targets across mental illnesses. As industry has backed away from investing in research and development for new medications and payers have raised questions about the evidence base for nonpharmacological treatments, NIMH has begun shifting its clinical trials portfolio toward studies with defined targets and milestones. In contrast to previous studies that looked only for statistical differences in efficacy, the Institute’s new experimental medicine approach seeks trials that will also reveal more about the mechanisms of disorders, serving as a foundation for better biomedical and psychosocial interventions.
Role of the Environment
A decade of progress in genomics has emphasized the importance of the environment in the pathogenesis of mental illnesses. For disorders like PTSD, trauma is by definition a major factor. But even in psychiatric disorders in which genomic factors are substantial contributors, like schizophrenia, research has demonstrated the importance of environmental exposures. The list of environmental issues spans individual factors, such as early adversity and the microbiome, to social factors, such as poverty and neglect. While the tools for the exposome are not as precise as tools for the genome, the mechanisms by which environmental factors alter the development of brain and behavior can now be studied and will continue to be a rich area of investigation going forward in each of the Strategic Objectives.
The success of RDoC and many other initiatives at NIMH requires a new culture of open science with broad and rapid data sharing. In this era of big data, revolutionary changes in data acquisition have created profound challenges, from storing massive quantities of data, to harmonizing and integrating data collections, to translating data into better knowledge, to addressing the impact on privacy and confidentiality. The National Database for Autism Research (NDAR) is an example of harnessing data sharing for collaborative science. Looking forward, the NDAR approach to collaborative data sharing will continue to grow, for example, through the National Database for Clinical Trials (NDCT), which will collect individual-level data from NIMH-supported clinical trials, and through the RDoCdb, which will collect data from relevant clinical studies. NIMH is committed to working with the scientific community to identify common data elements that can support the integration of data across studies and to support the broad sharing of data and the resources necessary to accelerate scientific progress.
Transforming the Trajectory of Mental Illnesses through Preemptive Medicine
Approximately 100,000 adolescents and young adults have a first episode of psychosis (FEP) each year in the United States.8 The majority of people with serious mental illnesses, even those with psychosis, experience significant delays in seeking care—nearly 2 years, on average.9,10 Through a series of major initiatives, NIMH is striving to improve early identification of individuals at high risk for FEP, to reduce the period of untreated psychosis to less than 12 weeks, and to maximize recovery among persons in the earliest stages of psychotic illness. The NIMH Early Psychosis Prediction and Prevention (EP3) initiative seeks to accelerate research on detecting risk states for psychotic disorders with the aims of preempting onset of psychosis in high-risk individuals and ultimately reducing the incidence to well below 100,000 cases per year, reducing the duration of untreated psychosis in individuals experiencing FEP, and improving clinical and functional outcomes among persons in the earliest stages of serious mental illnesses.
Global Mental Health
The challenges associated with mental illnesses are a global concern, and represent an opportunity to learn from, and with, other countries and other cultures. The rapidly increasing diversity of the U.S. population necessitates this global orientation. Worldwide, the distribution of morbidity associated with mental illnesses varies within and between countries. Within countries, disparities in mental health care and in the course and severity of illness occur along geographic and socioeconomic, as well as racial and ethnic, lines—as in the United States. Between countries, risk and protective factors, illness trajectories, and availability of quality care vary considerably. Addressing these shared challenges enriches the scientific enterprise overall, and will help us to advance U.S. research and to improve mental health care both domestically and globally. Insights from collective experience, along with varied perspectives, will inform mental health services and will help to find contextually appropriate solutions to reduce the burden of mental illnesses.
Mental Health Disparities
In U.S. mental health care, we see striking differences in illness prevalence and outcomes based on sex, gender, age, race, ethnicity, and geography. NIMH research needs to include adequate numbers of men and women and members of diverse racial/ethnic groups in studies—from genomics to services research—in order to detect and mitigate these disparities. In addition, studies of diverse populations can contribute to our understanding of risks for mental illness, responsiveness to prevention and treatment interventions, and access to and engagement in care. Specifically, research on sex, gender, age, racial, and ethnic differences related to mental disorders will provide information essential to the development of precision medicine and personalized interventions.
To achieve our public health mission, NIMH must work with external stakeholders who are also committed to the prevention, recovery, and cure of mental illnesses. By utilizing existing partnerships with many stakeholders—whether they are patients, their families, service providers, advocacy groups, sister agencies in the U.S. Department of Health and Human Services, private partners (both domestic and international), or others—NIMH can efficiently leverage our collective investments and research infrastructure, as well as help evaluate and learn from stakeholders’ experiences. In addition, rigorous collaboration, communication, and coordination between NIMH and its many stakeholders will lead to a quicker uptake of effective practices and programs. NIMH also seeks to develop new research partnerships, especially where there may be opportunities to harness developments in the fast-moving area of citizen-driven science. In all these ways, NIMH intends to maximize the impact of its research investments on the lives and outcomes of people with mental illnesses.
Investing in the Future
Finally, all research advances rest on our ability to support and train future generations of mental health researchers. NIMH will build on the guidance found in the National Advisory Mental Health Council Workgroup on Research Training report, Investing in the Future, to foster future generations of research scientists. Just as the research enterprise must adapt to a changing ecosystem, so must the training of future research scientists. Future research scientists must be prepared to use expanded biological, translational, clinical, and services skill sets to advance and transform the research enterprise across traditional academic boundaries. While the specific goals of NIMH-supported training were not included as part of this research plan, NIMH is committed to working with the scientific community to better understand future workforce needs and to inspire the next generation of committed scientists.
Accomplishing the Mission
The ecosystem in which NIMH works to accomplish its mission is rapidly changing. There are both new and existing cross-cutting interests that will influence the direction of mental health research as we move forward. Amid this sea of change, what future does NIMH envision, and how will this shape our journey?
The following sections of the Strategic Plan for Research outline at the highest level how NIMH proposes to confront the many challenges ahead as we envision a future where mental illnesses are prevented or cured. NIMH encourages the submission of investigator-initiated applications and responses to Requests for Applications aligned with this Plan. To foster the most germane applications, NIMH recognizes the research community’s need for more detailed guidance on specifics encompassed by the strategies in this Plan. Our Strategic Research Priorities describe areas of specific interest. The information within the Strategic Research Priorities pages on the NIMH website will be updated periodically to represent the most current interests of NIMH. We encourage you to check the site for the most recent insights on research needs.