12

Infrastructure for Prevention: Funding, Personnel, and Coordination

Like any other field, preventive intervention research cannot thrive without providing for its infrastructure. What levels of funding and personnel are necessary to implement the prevention research activities outlined in the earlier chapters? How can the entire enterprise best be coordinated? To begin to answer these questions, the committee first reviewed the existing federal presence in the prevention of mental disorders. It determined which agencies have relevant research and service programs and reviewed the funding, personnel, and training resources supporting these programs. The committee then reviewed current coordination efforts among federal agencies.

FUNDING

Estimates of funding levels for research on prevention of mental disorders were difficult for the committee to obtain for several reasons. First, the definitions of prevention and prevention research vary immensely across and within agencies. Basic research, risk identification studies, preventive interventions, treatment, and maintenance are all included in the U.S. Public Health Service's definition of “prevention research. ” Some agencies use this inclusive definition, and others do not. (See Chapter 2 for more discussion of this issue.)

Second, the definition of mental disorder varies. Although many agencies are doing work in this area, some of them do not see their activities as having anything to do with “mental disorders” because they use a narrow definition of that term. A broader definition, for example,



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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 12 Infrastructure for Prevention: Funding, Personnel, and Coordination Like any other field, preventive intervention research cannot thrive without providing for its infrastructure. What levels of funding and personnel are necessary to implement the prevention research activities outlined in the earlier chapters? How can the entire enterprise best be coordinated? To begin to answer these questions, the committee first reviewed the existing federal presence in the prevention of mental disorders. It determined which agencies have relevant research and service programs and reviewed the funding, personnel, and training resources supporting these programs. The committee then reviewed current coordination efforts among federal agencies. FUNDING Estimates of funding levels for research on prevention of mental disorders were difficult for the committee to obtain for several reasons. First, the definitions of prevention and prevention research vary immensely across and within agencies. Basic research, risk identification studies, preventive interventions, treatment, and maintenance are all included in the U.S. Public Health Service's definition of “prevention research. ” Some agencies use this inclusive definition, and others do not. (See Chapter 2 for more discussion of this issue.) Second, the definition of mental disorder varies. Although many agencies are doing work in this area, some of them do not see their activities as having anything to do with “mental disorders” because they use a narrow definition of that term. A broader definition, for example,

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH would include substance abuse and dependence. Other agencies use legal terminology such as “delinquency” rather than mental disorder diagnoses such as conduct disorder, although the terms often apply to the same people. Once it is generally acknowledged that precursors to mental disorders include behavioral dysfunction and clusters of serious psychological symptoms that do not yet meet full criteria for diagnosis, it is expected that more agencies will acknowledge their role in preventing these mental health problems. Moreover, agencies actively involved in prevention of physical illnesses, such as the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), often do not appreciate that an important outcome of their work is reduction of psychiatric morbidity. Thus the psychiatric consequences of preventive interventions for physical disorders need to be emphasized. With more consensus on these definitional issues, estimates of actual funding levels will be more easily obtained. Third, data retrieval systems for information on research funding are difficult to access, inadequate, and sometimes misleading.* Data from an NIH Retrieval System The committee reviewed data from the Research Documentation Section, Information Systems Branch of the Division of Research Grants at NIH. The division supplied Computer Retrieval of Information on Scientific Projects (CRISP) files of funded prevention research across NIH and the former Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA; which contained the three research institutes, the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA)). In the CRISP files, prevention research is classified by type: mental disorder prevention, alcoholism prevention, and drug abuse prevention. It is also classified by emphasis level, that is, the relevance of the indexing terms to the aims and objectives of the project. The emphasis codes are P = primary, S = secondary, T = tertiary, and M = main. (These codes should not be confused with terms used to describe types of intervention within the public health classification *The Prevention Research Branches (PRBs) of NIMH, NIDA, and NIAAA initially found it difficult to comply with the committee's requests for lists of funded research grants back to 1988. The emphasis in the branches is on the current funding year, and hard-copy archives are not kept officially for more than a couple of years. (If they are, it is often by an efficient long-time support staff person.) Computers in the agency budget offices have eased these storage problems, and computerized lists are available.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH system discussed in Chapter 2.) Main (M) emphasis codes are used only for parent projects of multiproject awards and are equivalent to the primary (P) emphasis level. Therefore, in the committee's review, main and primary levels were combined. All items that appear in a CRISP printout are peer reviewed when they are proposals. However, the type of peer review required varies according to whether the monies are intended for a grant or a contract. A contract proposal is not reviewed by the same standards or mechanisms as a grant proposal. The contract proposals are reviewed through a process called a secondary review, in which the review committee is composed of a certain percentage of NIH personnel and a certain percentage of outside experts. The difficulty in assessing the funding commitments by federal agencies to prevention research is dramatized by the CRISP recording system at NIH. The CRISP system has a number of serious problems when used to evaluate research programs. First, when funded projects come into the system, they are classified by a staff person. Classifications are not consistent, in part because a written definition of prevention has not been available for guidance. Second, the data are not complete. For example, the CRISP lists of research projects did not match the portfolios of funded grants supplied by the relevant program officers at NIMH and NIDA. Only 24 of 80 grants funded from 1988 to 1992 by the NIMH Prevention Research Branch (PRB) were even listed by CRISP as having a main/primary area of emphasis on prevention. Third, the same project can be classified in more than one prevention area, for example, alcoholism prevention and mental disorder prevention. Fourth, there is no limitation on how many times a particular project can be classified by emphasis code. For example, in fiscal year (FY) 1991, 41 research projects (which were funded by NIMH, NIDA, NIAAA, the National Institute of Child Health and Human Development (NICHD), and the National Center for Research Resources (NCRR)) were identified as having a main/primary emphasis in mental disorder prevention. The projects totaled $13,675,607. The numbers of other primary, secondary, and tertiary areas of emphasis that each particular grant was classified as having were counted. These included areas as diverse as “psychometrics ” to “social control” to “immunopathology.” The 41 projects had 264 primary areas of emphasis in addition to mental disorder prevention, 312 secondary areas, and 114 tertiary areas. The committee concluded that the CRISP system can miss directly relevant projects, on the one hand, and also can produce extensive multiple counting of projects on the other, which can result in mislead-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH ingly large estimates of efforts in a particular area. However, CRISP is one of the few available sources of data on prevention research projects. Table 12.1 shows the dollars awarded and the number of research projects and subprojects for mental disorder prevention, alcoholism prevention, and drug addiction prevention by NIH and ADAMHA. All of these data were compiled from CRISP printouts. A few of the agencies identified by CRISP as having scientific projects in mental disorder prevention, drug addiction prevention, or alcoholism prevention have received only contracts, not grants. For example, see the column on drug addiction prevention in Table 12.1 for FY 1992. The Office of Substance Abuse Prevention (OSAP; now the Center for Substance Abuse Prevention (CSAP)) had 22 projects or subprojects totaling $102,112,353. Upon examination, all of these projects were contracts. The Office for Treatment Improvement (OTI) also had only contracts. NIAAA and NIMH, on the other hand, had only grants. NIDA had 53 grants and 11 contracts. In total, 43 percent of the FY 1992 drug addiction prevention projects were contracts, not subject to the same standard of review as grants. They totaled $135,247,179. In contrast, the grant monies totaled $20,807,047. From the CRISP data, the following points are clear: Research on prevention of mental disorders, alcoholism, or drug addiction is not the domain of any one agency; rather, many agencies are involved. Expenditures for research on prevention of alcoholism and drug addiction have been far more than for research on prevention of other types of mental disorders. OSAP was created in 1990. The following year, NIMH's role in research on the prevention of drug addiction and alcoholism was drastically decreased. OSAP is not listed as having had any role in research on the prevention of mental disorders, but it has received far more money for research on alcoholism prevention and drug addiction prevention than any other office or institute within the former ADAMHA or NIH. The type of peer review and the number of grants versus contracts vary enormously across the agencies. Data from an ADAMHA Draft Report and from the PRBs The ADAMHA Reorganization Act of 1992 transferred the three ADAMHA research institutes (NIMH, NIDA, and NIAAA) to NIH and established the Substance Abuse and Mental Health Services Adminis-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 12.1 Prevention Research Projects Funded by Agencies of NIH and the Former ADAMHA According to CRISP Definitions and Files   Mental Disorder Prevention (1838 8404*)   Alcoholism Prevention (0080 8999*)   Drug Addiction Prevention (0962 7764*)     Dollars Awarded Number of Projects and Subprojects Dollars Awarded Number of Projects and Subprojects Dollars Awarded Number of Projects and Subprojects FY 1988             NCRR 71,361 2 — — — — NIAAA 269,977 1 7,444,876 38 1,204,549 6 NIDA 245,143 1 955,839 5 12,868,727 44 NIDR 77,370 1 — — — — NIMH 4,596,638 18 5,467,078 2 5,983,948 3 NINDS 186,137 1 — — — —   ——— — ——— — ——— — Totals 5,446,626 24 13,867,793 45 20,057,224 53 FY 1989             DM-BHP 74,457 1 — — — — NCNR 271,759 1 — — — — NCRR 112,927 3 — — — — NIAAA 238,459 1 8,561,792 43 1,208,791 6 NICHD 121,729 1 — — — — NIDA 339,425 1 1,124,714 6 19,784,468 52 NIMH 5,253,651 22 7,015,665 17 7,532,535 18   ——— — ——— — ——— — Totals 6,412,407 30 16,702,171 66 28,525,794 76 FY 1990             NCNR 151,814 1 — — — — NIAAA 343,634 1 12,711,923 51 1,790,248 8 NICHD 380,392 2 — — — — NIDA 381,426 1 3,664,251 9 31,894,783 73 NIMH 9,073,690 28 7,015,665 17 7,532,535 18 OSAP — — 37,802,237 6 44,001,150 10   ——— — ——— — ——— — Totals 10,330,956 33 61,194,076 83 85,218,716 109 FY 1991             NCNR — — 25,000 1 — — NCRR 18,089 1 — — — — NIAAA 237,431 1 13,090,473 44 1,753,583 6 NICHD 1,654,804 4 — — — — NIDA 394,493 1 1,773,918 5 30,498,900 64 NIMH 11,370,790 34 487,432 5 487,432 5 OSAP — — 66,139,480 11 71,849,809 14 OTI — — —   564,542 2   ——— — ——— — ——— — Totals 13,675,607 41 81,516,303 66 105,154,266 91   Mental Disorder Prevention (1838 8404a)   Alcoholism Prevention (0080 8999a)   Drug Addiction Prevention (0962 7764a)     Dollars Awarded Number of Projects and Subprojects Dollars Awarded Number of Projects and Subprojects Dollars Awarded Number of Projects and Subprojects FY 1992             NCNR 194,672 1 25,000 1 — — NCRR — — 49,866 1 — — NIAAA — — 13,915,829 47 1,540,862 5 NICHD 1,773,029 3 — — — — NIDA 373,728 1 2,793,995 6 32,396,908 64 NIMH 13,444,251 40 487,432 5 487,432 5 OSAP — — 93,548,289 19 102,112,353 22 OTI — — 18,952,129 14 19,516,671 16   ——— — ——— — ——— — Totals 15,785,680 45 129,772,540 93 156,054,226 112 Abbreviations used are as follows: DM-BHP Division of Medicine - Bureau of Health Professions NCNR National Center for Nursing Research NCRR National Center for Research Resources NIAAA National Institute on Alcohol Abuse and Alcoholism NICHD National Institute of Child Health and Human Development NIDA National Institute on Drug Abuse NIDR National Institute of Dental Research NIMH National Institute of Mental Health NINDS National Institute of Neurological Disorders and Stroke OSAP Office of Substance Abuse Prevention OTI Office for Treatment Improvement aCodes used by CRISP to identify areas of emphasis. NOTE: See text for problems related to definitions and classification in the NIH Computer Retrieval of Information on Scientific Projects (CRISP) system.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH tration (SAMHSA) with the following three agencies: the Center for Substance Abuse Treatment (CSAT), CSAP (formerly OSAP), and the Center for Mental Health Services (CMHS) (see Table 1.1 in Chapter 1).* This division between research and services entailed intense debate, and the advantages and disadvantages created by the reorganization are likely to be reviewed for many years to come. The original ADAMHA legislation required ADAMHA to prepare a report on its prevention activities every three years and submit this to *This reorganization occurred in the middle of the committee's review of the status of prevention research.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 12.2 Prevention Activities Funded by NIMH, NIDA, and NIAAA (dollars)   NIMH   NIDA   NIAAA     Total Institute PRBa Total Institute PRBa Total Institute PRBa 1989 57,758,000 7,849,953 132,866,000 7,484,255 14,852,000 9,641,271 1990 77,945,000 15,153,315 168,853,000 16,612,418 21,337,000 16,521,839 1991 93,062,000 18,866,198 166,460,000 19,961,232 27,220,000 19,254,403 1992 —b 21,262,514 —b 19,731,873 —b 23,166,210 aPrevention Research Branch. bNo ADAMHA report was prepared for Congress. NOTE: Figures for 1989–1991 totals are from the draft ADAMHA “Report to Congress on Prevention Activities 1989–1991.” Figures for the NIMH and NIDA PRBs were compiled from the lists of grantees provided by the PRBs. Figures for the NIAAA PRB came from the NIAAA Budget Office. See text for problems related to definitions of prevention. Congress. In 1992 a draft report was prepared by the ADAMHA director and submitted to the Secretary of the Department of Health and Human Services (DHHS). The committee used the figures from this draft report in its review of prevention. However, in 1993 the report was withdrawn; it was not submitted to Congress or released to the public.* This was because the legislative requirement for the report had been repealed by section 101 of the ADAMHA Reorganization Act of 1992. The draft report included ADAMHA prevention activities and expenditures during fiscal years 1989, 1990, and 1991, including extramural and intramural research, service demonstrations, professional training and education, block grants, and miscellaneous activities, but excluding HIV/AIDS prevention. Prevention expenditures were reported as $382,529,000 in 1989, $643,792,000 in 1990, and $749,093,000 in 1991. Table 12.2 shows the prevention expenditures reported by ADAMHA for each of the research institutes in 1989, 1990, and 1991. It also shows the grants funded by the Prevention Research Branches within those institutes during those years and 1992. These data came from the PRBs directly, not from the ADAMHA report. The differences in the expenditures are substantial. If the figures are accurate, most prevention activities took place outside the PRBs. However, this difference in reported expenditures dramatizes the problem of definition of prevention of mental disorders and the immense discrepancy in *The committee acquired the report through the use of the Freedom of Information Act.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH expenditures between service and research and between different types of research. The ADAMHA report stated that during 1991 OSAP expenditures for prevention were $271,465,000, yet CRISP reported OSAP as having spent $71,849,809 on drug abuse prevention research and $66,139,480 on alcoholism prevention research during the same year. This difference reflects the amounts spent on services versus research, with the CRISP data reporting on research. The Prevention Research Branches within the three research institutes —NIDA, NIAAA, and NIMH—vary in their research emphasis. Within the NIAAA PRB, there is both risk identification research and preventive intervention research. The branch increasingly has focused on youth and young adults, women, the elderly, and minorities. It has examined the effects of regulatory policies within the community and is interested in doing research on alcohol-related violence. The NIDA PRB is within the Division of Epidemiology and Prevention Research. The division has conducted several large, well-known epidemiological studies, but several of those have now been moved to SAMHSA; the division continues to sponsor risk identification research, and preventive intervention research at the individual, social environment, and community levels. A new initiative within this PRB is an effort to create prevention centers focused on testing culturally and ethnically sensitive preventive interventions. NIMH conducts prevention-related activities throughout its branches, but most of its preventive intervention research is within its PRB. Only two of the three PRBs—those at NIDA and NIMH—have their own centers for prevention research. These centers are specialized, focusing on topics across the life span. NIAAA also has one, but it is not part of the branch. NIAAA's Prevention Research Center, in Berkeley, California, conducts basic research on identification of risk factors that contribute to alcoholism, including factors in the individual, family, peer group, work site, and community. It has initiated community preventive intervention trials to assess the effects of changes in availability of alcohol, such as minimum age of purchase and service interventions at restaurants and bars. Table 12.3 provides the history of funding levels for the NIMH prevention centers, called Preventive Intervention Research Centers (PIRCs), which were begun in 1983. Table 12.4 provides a similar history for the NIDA prevention centers, called Prevention Research Centers, which were begun in 1987. Overall, these centers in both institutes started with relatively modest support, and their current annual budgets average about $1 million per year per center. A major difference in the centers is that those at NIMH all focus on preventive

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 12.3 Support Received for the NIMH PRB Preventive Intervention Research Centers (PIRCs) (dollars) Fiscal Year Hahnemann University (P50MH38425a,b) University of Michigan (P50MH39246a) Albert Einstein College of Medicine (P50MH38280a) Johns Hopkins University (P50MH38725a) Arizona State University (P50MH39246a) Oregon Social Learning Center (P50MH46690a) 1983 289,000 245,814 461,124 — — — 1984 367,121 330,578 339,263 407,788 307,350 — 1985 295,750 263,007 506,829 439,761 282,361 — 1986 — 434,330 418,295 398,475 260,088 — 1987 — 497,988 497,948 427,810 312,207 — 1988 — 486,791 — — 272,405 — 1989 — 130,000 806,500 — 130,000 — 1990 — 1,158,135 853,838 825,296 982,157 742,298 1991 — 807,757 925,456 1,102,418 765,815 1,099,980 1992 — 527,603 836,481 1,490,000 1,115,035 1,296,270 1993 — 722,947 672,145 1,637,851 1,282,436 1,348,120   —— —— —— —— —— —— Totals 951,871 5,604,950 6,317,879 6,729,399 5,709,854 4,486,668 aResearch grant numbers. bDiscontinued. NOTE: Figures are from the NIMH Budget Office.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 12.4 Support Received for the NIDA Epidemiology and Prevention Research Centers (dollars) Fiscal Year University of Coloradoa (P50DA05131b) Western Psychiatric Institute, Pittsburgh, Pennsylvaniaa (P50DA05605b) Center for Prevention Research, Lexington, Kentucky (P50DA05312b) Columbia University (P50DA05321b) Colorado State University (P50DA07074b) Cornell University Medical College (P50DA07656b) 1987 — — 526,091 — — — 1988 399,500 — 527,965 658,451 — — 1989 397,873 933,040 564,275 714,948 — — 1990 414,671 952,960 431,299 676,427 779,485 — 1991 — 1,139,478 425,593 628,645 1,074,900 747,912 1992 844,653 1,200,835 1,003,734 844,820 1,072,500 1,003,626 1993 832,478 1,280,931 1,133,323 — 1,063,250 1,218,000   —— —— —— —— —— —— Totals 2,889,175 5,507,244 4,612,280 3,523,291 3,990,135 2,969,538 aFocused on epidemiology and risk research, not on preventive intervention research. bResearch grant numbers. NOTE: Figures are from the NIDA Budget Office.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 12.5 Breakdown of NIMH Prevention Research Branch Budget for FY 1992   Number of Grants Grants Amount (dollars) Prevention of socioemotional problems among high-risk infants and toddlers 8 2,231,974 Prevention of conduct disorder in school-age children (including two PIRCs) 11 6,004,495 Prevention of anxiety and depression resulting from stressful life conditions (including three PIRCs) 15 4,498,796 Enhancement of coping mechanisms 2 202,664 Methodology 3 282,839 Research Scientist Award 2 197, 618 Research training 3 206,136 Clinical training 19 1,112,993 Research demonstrations     Prevention of conduct disorder 3 5,461,425* Prevention of youth suicide 3 1,063,574 Suicide research conference 1 0   — ——— Totals 70 21,262,514 *This total includes a RO1 research grant of $1,102,000. NOTE: Figures are from the NIMH Prevention Research Branch. intervention research, whereas at NIDA two focus on risk research and four focus on preventive intervention research. These latter four are within the PRB. The breakdown of the NIMH PRB budget for FY 1992 is shown in Table 12.5. Most of the research grants are in three important areas: socioemotional problems among high-risk infants and toddlers, conduct disorder in school-age children, and anxiety and depression resulting from stressful life conditions. Half of the budget supports RO1 research and research demonstrations in the area of conduct disorder. (The research demonstrations are not to be confused with large-scale field trials as described in Chapter 10.) Very few grants are awarded to research on enhancement of coping mechanisms or on the development of methodology, although some methods development does occur within the PIRCs. Five times more is spent on clinical training than on research training. A review of the clinical training grants showed them to be part of the Depression Awareness, Recognition and Treatment Program, which is clearly treatment rather than prevention by the committee's definition.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH future. All of these observations are what one would expect in a new and developing field, still defining and organizing itself. The Current Research Training Picture The current preventive intervention research training effort is organized in such a fashion and funded at such a low level that an outside observer could reasonably conclude that policymakers wish to phase out investment in this field. Current institutional training programs are small and typically involve a 2-year training period. There may be five such programs in the entire United States, and the current output of trained (by the committee's standard) preventive intervention researchers from these institutional programs may be about 10 persons per year (assuming continuing funding and program viability). Additionally, there may be about 12 persons being trained on individual awards during any 1 year, with about half of them finishing their training each year. The principal federal agencies that currently support research and training on prevention of mental disorders are NIMH, NIDA, and NIAAA. In FY 1992, NIMH supported three institutional training programs: Arizona State University at $117,237; Johns Hopkins University at $63,899; and Yale University at $25,000. The latter grant was terminated in FY 1993 because the principal investigator moved to another institution. During the last 6 years, these three programs have had a total of 23 postdoctoral students and 10 predoctoral students. Of the 23 postdoctoral students, 2 were physicians, 1 was a nurse, and 20 were psychologists. In 1992, the NIDA PRB had one institutional research training grant for 3 predoctoral and 3 postdoctoral trainees, all from nursing, and the NIAAA PRB awarded two institutional training grants, one for postdoctoral psychology training in alcohol research at the University of Washington and the other at the University of Georgia for research training on employee alcoholism. The program at the University of Washington, which has been in existence for 10 years, trains postdoctoral psychology students at a rate of 3 to 4 per year and some predoctoral students. The focus is on risk identification research as well as intervention research that is not restricted to prevention. The program at the University of Georgia, in existence for 5 years, has trained 9 postdoctoral students (5 sociologists, 3 psychologists, and 1 anthropologist; 6 women, 3 men; no minorities). The research focus of the center is on alcohol and the work site. Approximately half of the 9 students were interested in prevention, the other half in treatment. In 1993 the program had only 1 postdoctoral student and 7 predoctoral students.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 12.8 NIMH Grant Mechanisms That Can Be Used for Research Training or Related Activities F30 National Research Service Award for Individual Predoctoral Fellows (M.D./Ph.D. Fellowships) F31 Predoctoral National Research Service Award Individual Fellowship F32 Postdoctoral National Research Service Award Individual Fellowship F34 Minority Access to Research Careers Faculty Fellowship K02 Research Scientist Development Award K05 Research Scientist Award K21 Scientist Development Award K20 Scientist Development Award for Clinicians R24* Minority Institutions Research Development Program R24* Research Infrastructure Support Program T14 and R13 Research Conference Grant T32 National Research Service Award for Institutional Grants T34 Minority Access to Research Careers: Honors Undergraduate Research Training Grants T35 Short-term Institutional National Research Service Award *Minority Supplement Award as well as Disability Supplement Award can be applied. In addition to the institutional training programs, the research institutes have awarded some individual traineeships. In 1992 the NIMH PRB had 2 Research Scientist Awards; the NIDA PRB had 2 postdoctoral individual fellowships, 1 Research Scientist Development Award, and 6 Minority Supplement Awards; and the NIAAA PRB awarded 2 individual fellowships. Other federal agencies such as MCHB, CDC, and the Department of Defense (DOD) have the potential for developing research training programs with a clear focus on preventive interventions for mental disorders. The crisis in prevention research training reflects a larger crisis in training in the entire mental health area. Although there are many grant mechanisms available at NIMH for research training (see Table 12.8), the levels of support are inadequate. Stipends from NIH are $8,800 per year for a predoctoral student, in comparison with $15,000 at the Department of Defense, $15,500 at the National Science Foundation, and $15,000 at the Department of Education. Postdoctoral stipends at NIH are $18,600 to $33,300. These stipends are taxable and do not include health insurance. Training-related expenses that are covered for predoctoral students amount to $1,500 and $2,500 for postdoctoral students, and there are no funds for research support. Such small training grants have an especially adverse effect on minorities, who may be unable to supplement the stipends with personal or family funds. The current demand for prevention research training can be estimated

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH by the number of applicants for training positions. Because the numbers are small and fluctuate from year to year, the committee again must make rough estimates, but these numbers suggest that for now demand and supply are roughly in balance. There may be a slight surplus of applicants for training, but this may be desirable because it permits training institutions to make selections on the basis of quality. Until more high-quality research projects are funded, the supply of applicants for training positions is likely to remain small because many potential candidates will not see prevention as a viable and growing field. The directors of training whom the committee has queried report that most graduates of their programs are employed, mostly at academic institutions and many in positions with responsibility for prevention research in funded projects. A Model for Training Prevention Researchers It is important to begin to identify optimal training models and to develop mechanisms for sustaining financial support. One way of looking at the training of preventive intervention researchers is to ask what should such researchers (or research teams) know? By its nature, research in the prevention of mental disorders requires the ability to assess evidence regarding risk and protective factors—both biological and psychosocial—for onset of the various mental disorders; transform this knowledge, if sufficient, into preventive interventions; design, conduct, and analyze preventive interventions in the real world; and incorporate sound decisions regarding cultural, ethical, and economic issues into preventive intervention research. As is clear from the description of the preventive intervention research cycle in Chapter 10, this research is inherently interdisciplinary, requiring knowledge of several core sciences (including genetics, epidemiology, and psychology) as well as postdoctoral experience in the specific methods of preventive intervention research. It requires familiarity with all of the disciplines normally associated with mental health, as well as other disciplines that are relevant to innovations in various social and mental health services, school systems, and communities. The committee believes that conventional disciplinary training in any one of the fields ordinarily concerned with the diagnosis, assessment, and treatment of mental illness is not sufficient to prepare individuals for a research career in prevention, although it is necessary. In other

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH words, training in preventive intervention research should start with individuals who have already acquired knowledge and skills in such areas as nursing, social ecology, sociology, social work, public health, epidemiology, medicine (especially pediatrics, child psychiatry, and psychiatry), and clinical, developmental, social, and community psychology. In addition to exposure to one or more of these basic approaches to a broad understanding of human behavior, training in preventive intervention research requires two other kinds of education or experience: (1) the design of interventions to prevent mental illness and (2) the analysis of the efficacy and effectiveness of an intervention. The intellectual orientations and methodological skills required for program design do not ordinarily receive much attention in the predoctoral programs of the behavioral sciences, and only slightly more in the practice-oriented fields of psychiatry and social work. Analysis demands still different orientations and skills, such as population perspective, that are almost entirely omitted from the “practice” disciplines and are only partially covered by other behavioral sciences. A program to train prevention researchers will require not only careful crafting of flexible and wide-ranging programs, but also close attention to each trainee's skills and knowledge deficiencies, careful mentoring and monitoring of progress, and suitable practicum experiences as well as didactic instruction. Training in research design must be concerned with understanding the phenomena at issue: the nature and epidemiological distribution of the risk or protective factor that is to be reduced or enhanced. Knowl-edge of the particular mental disorder necessarily precedes and underlies an effective prevention strategy. Prevention programs should be based on sound research into the causes of mental disorders and also must go beyond that to understand how the disorders are manifest in everyday life. Further, training in design must invoke the know-how of implementing in practice an innovative idea that may have emerged from basic research. Training in research focuses on learning how to obtain a dependable and unequivocal answer to the question of whether a particular intervention was indeed efficacious and effective in preventing mental disorder. Training also concentrates on learning about the processes by which the outcomes occurred, especially if the outcomes were not good. The questions are deceptively simple. The complications that make them difficult arise from the variability in human behavior, chance events in individual lives, errors in measurement, a tendency to overemphasize a few outstanding successes while ignoring a larger number of indifferent outcomes, and a myriad of other factors. Dependable

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH answers almost always require comparing a group that did receive a particular preventive intervention with a group that did not, and that feature brings into question not only how the experimental group was selected, but also the ethical propriety of intervening with some individuals and not others. These are the generic issues that training in research must confront. Training in preventive intervention research requires direct experience in established institutions or centers carrying out prevention studies. A central feature of this model training program is the incorporation of practicum or internship-like training, as well as classroom or other didactic instruction. The trainee's experience should include participation in all phases of an actual preventive intervention research program that is being conducted by the faculty of the training institution. The trainee's mentors need to have had actual experience in one or more phases of design and analysis, and at least some of them should be actively engaged in such tasks during a trainee's participation. A clear implication is that the training institution itself must be actively engaged in a continuing program of preventive intervention research, perhaps with shifting emphases and different types of intervention, but steadily engaged. Although this kind of training is available in medical or relevant doctoral programs, it is not common in the education of human resources professionals. First, it is labor-intensive and expensive. Second, it is not easy to identify and bring together the range of talents needed for the training faculty. The model program depends, in most instances, on interdisciplinary collaboration, which can be disrupted by academic mobility. It is hard to see how such training could be provided without external support, for the costs of faculty as well as trainees. Fellowships for individual trainees alone will not suffice. As discussed earlier, current federal training grants cover only a small fraction of such training and are subsidized heavily by the training institution and by research grants from NIH. The committee concludes that a long-term strategy for preventive intervention research training should be developed at the postdoctoral level. There is a significant demographic change that may have an impact on this strategy. In the last decade or so, the number of faculty positions at research universities has been limited, and many graduates of doctoral programs in the social and behavioral sciences, public health, and other fields have been willing to accept postdoctoral traineeships while they waited for openings to occur. In the next decade, a substantial number of retirements from the faculty are expected among those who were appointed during the expansion years of the 1960s. For other

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH demographic reasons, there is likely to be, simultaneously, a smaller number of entrants into doctoral programs in fields related to prevention research. These two trends are likely to increase the demand for new Ph.D.s on faculties, thus making the traineeship less attractive, even with the prospect of an additional two years of training. Two possible solutions suggest themselves: one is to begin prevention research training earlier, say just before completion of disciplinary training. The other is to recognize the real costs of mid-career training for mature scientists with family obligations. The committee believes that support for both is necessary. Postdoctoral training is a long-term strategy for increasing the number and quality of prevention researchers. What is needed immediately is a short-term strategy to “jump-start” the field. Mid-career scientists from related fields—risk identification research, epidemiology, treatment effectiveness research, and research on prevention of physical disorders —need to be recruited, trained, and adequately supported through increased stipends and increased availability of research grants. It is possible that this presentation of a model training program may be misunderstood as being unduly narrow and rigid. The description should be taken as an indication of what the committee believes to be both desirable and feasible, without ruling out other possible approaches to the same goal. The field of prevention research should be open to additional training models as experience accumulates; a narrow prescription for training would be inappropriate at this time. Conclusions The committee concludes that the national interest in the prevention of mental disorders requires the following general strategies for building training capacity: A gradual increase in the number of investigators trained and experienced in preventive intervention research. An increase in the number of physicians, nurses, and social workers trained in preventive intervention research. To “jump-start” the field, fellowships as well as intensive short-term training for mid-career scientists who wish to change fields and spend all or part of their time collaborating with an interdisciplinary preventive intervention research team. The development of more postdoctoral training programs. An increase in funding for both training and research. A large part of the training the committee recommends occurs during participation

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH in research projects under the supervision of mentors. As indicated earlier, the training and research enterprises need to be coordinated so that the trainees are available to fill the need for researchers, both the need for researchers in an expanding research enterprise and the replacement of those who retire or leave the field. The creation of a career line that makes prevention research a rewarding profession, attracts high-quality talent, and sustains persistent attention to the difficult problems related to prevention of mental disorders. Such a career line includes forums for professional exchange, opportunities for continuing professional growth, and academic recognition of professional contributions, as well as mechanisms by which research, and researchers, can actually influence prevention programs and policy. This capacity-building process will be a long-range effort, because the base from which it starts is small, and the start-up of new training programs is bound to be slower than the rate at which well-trained investigators can be effectively used. High-quality training is essential, and it will take time for potential new training institutions to assemble the required mix of professional talent. Leadership will have to be found within federal and state governments, universities, and foundations. Research training projects will require the cooperation of treatment and prevention agencies willing to try out new interventions and allow their efforts to be evaluated. Some training models may not be successful. The first 5 years will build capacity slowly, and it is important to have realistic goals for these years. After a few years, with successful models for training programs, with developing career lines and the assurance of funding for prevention research, it is hoped that the curve of output growth will accelerate sharply—to the point where more ambitious long-range goals can be realistic. Accordingly, the committee suggests both 5-year and 10-year targets for the size of the training enterprise. The committee's 5-year goal is to produce enough trained investigators in prevention research to provide staff for the larger number of training programs it envisions, for additional specialized prevention research centers in organizations that support research generally, and for research positions in some education and social service departments that now are, or soon will be, able to use their talents as these departments increase their standards for rigorous evaluation of program effectiveness. The committee's 10-year goal is to provide preventive intervention researchers in high-quality programs in major academic settings, in many departments of education and other social service

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH agencies at the state level, and in all of the training programs and specialized prevention research centers that are expected to be in place at that time. To achieve such a goal will require support from federal, state, and private sources. Finally, mechanisms must be created that make it feasible and even attractive for talented mid-career scientists to switch into preventive intervention research. Mechanisms to accomplish this include research scientist awards and awards to establish chairs for distinguished scientists in prevention research. Both of these mechanisms have precedents within NIH. As with the institutional training grants, it is essential that these programs cover the full costs. If policymakers decide that the national interest requires the development of this field, then barriers to that development must be completely removed. COORDINATION Federal agencies doing preventive intervention research and providing prevention services are decentralized and uncoordinated and have minimal awareness of each other's efforts. Few projects directly assess or attempt to intervene in the common phenomenon of co-morbidity among mental disorders, including drug and alcohol abuse. Even though NIMH is clearly the lead agency in research regarding the etiology and treatment of mental disorders, it has not taken a lead role in regard to the exchange of knowledge about preventive interventions with other federal agencies or with state agencies. In part, this lack of leadership regarding prevention knowledge exchange reflects the biomedical emphasis of NIMH, but it also is a result of NIMH 's inability to coordinate its prevention programs with NIDA and NIAAA and other federal programs. Because many other DHHS agencies, such as SAMHSA, the Administration on Children, Youth and Families (ACYF), CDC, and HRSA; other departments, such as Education and Defense; and state agencies conduct their own preventive intervention research and provide prevention services, it is essential that coordination efforts include them as well as the NIH research institutes. There is no central clearinghouse within the government on prevention of mental disorders. There have been few prevention conferences outside of a single institute or agency. There is no organized system for the exchange of knowledge regarding prevention research, including effective intervention programs, with state public health departments, advocacy groups, or universities (see Chapter 11). Many problems that exist within the federal government also exist in the network of private foundations mentioned earlier in this chapter.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH For many years, these foundations and many others have provided substantial research and service funds for prevention, including the reduction of various risk factors associated with the onset of mental disorders. The network for information sharing and joint funding of projects among federal agencies and private foundations is an informal one, relying heavily on the individuals involved, much as it is within the federal agencies. The extent to which the private and public funding sources overlap to provide for the career development of prevention researchers and for joint sponsorship of research projects could not be determined because there is no mechanism for recording this type of information. However, it appears that the overlap, at least sequentially, for a particular project or researcher may be considerable. To coordinate these diverse participants in prevention, a lead agency would require several attributes. The ability of the lead agency to bring together all the interested federal, state, and private parties to facilitate an open sharing of ideas and information, a commitment to the investigations of multiple, co-existing risk conditions for mental disorders and the co-morbidity of dysfunctions and disorders, and a willingness to participate in joint projects are all essential. A commitment to prevention, as distinguished from treatment and maintenance, is equally important in the lead agency. To place such a leading role outside the federal government does not seem possible, because the bulk of funds for preventive intervention research and service will continue to come from the federal government. The reorganization of ADAMHA complicates the picture. With the split between research and services, none of the remaining agencies covers all the bases. SAMHSA has a clear role in the delivery of preventive services regarding drug abuse, but its role in prevention of other mental disorders is less clear. Although prevention is part of the mandate to SAMHSA's Center on Mental Health Services, there is no mandate establishing an Office of Prevention, and no support for prevention coordination was authorized. Each of the three research institutes at NIH (NIMH, NIDA, and NIAAA) has an Office of Prevention. The new law does not, however, establish any overarching authority to coordinate their activities, and categorical funding has contributed to competitiveness and isolation of the institutes from each other. It remains to be seen how these three research institutes will dovetail with the already established Health and Behavior Committee and Prevention Coordinating Committee at NIH. The links between the research institutes and the service programs at ADAMHA were already tenuous; coordination may now be even more difficult.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Furthermore, the research grant review process is fraught with difficulties across the institutes. These include lack of high-quality proposals, lack of proposals from minority investigators, lack of expertise in preventive intervention research on review committees that sometimes consider epidemiology, treatment, and prevention grants, vested interests on review committees that are dominated by “inside” prevention scientists (partly because prevention is still a small and young field), and reluctance of some review committees to allow investigators to combine funding streams from different institutes or agencies or to cross from one institute to another. Even though other agencies, such as the Maternal and Child Health Bureau and the Administration on Children and Families within DHHS, as well as the Department of Defense, the Department of Education, and the Department of Justice, are valuable contributors and should be included in any coalition-building effort, none has enough current expertise on mental disorders to become the lead agency. The Office of Health Promotion and Disease Prevention has had an important role in coordinating information about prevention services and research within DHHS, but it too lacks expertise on mental disorders. Some of these agencies also lack expertise in research methodology. The Centers for Disease Control and Prevention clearly has the best delineated mandate for prevention among federal agencies, and it has excellent outreach capabilities through public health departments. Recently, it has taken a more active role in prevention of violence and the prevention of problems associated with low birthweight. However, its current expertise in mental disorders is quite limited. Conclusions There is little coordination of prevention research or prevention services across federal agencies, or among federal agencies, universities, and private foundations. In addition, research institutes and agencies frequently ignore issues of co-morbidity of mental disorders and of mental and physical disorders, as well as the co-existence of mental disorders and social and legal problems, such as delinquency. A less categorical approach to interventions may be productive to individuals as well as society, but there is no clear lead agency to provide such an approach. No agency has both the expertise in mental disorder preventive intervention research and an established track record in working collaboratively with other agencies and departments on prevention. Therefore the committee concludes that an alternative mechanism is

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH needed so that research and services on prevention of mental disorders can be coordinated across the federal departments. REFERENCES ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration). ( 1993) Prevention Activities of the Alcohol, Drug Abuse, and Mental Health Administration: Report to Congress FY 1989 to 1991; Draft received in 1993 through the Freedom of Information Act. DHHS (Department of Health and Human Services). ( 1992) Public Health Service. Office of Disease Prevention and Health Promotion. Prevention '91/'92 Federal Programs and Progress. Washington, DC: Government Printing Office; 332–838. OBRA (Omnibus Reconcilitation Act). ( 1989) Maternal and Child Health Block Grant Program. P.L. 101–239, Title VI, Subtitle C; Enacted December 19, 1989.