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Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (1994)

Chapter: 12 Infrastructure for Prevention: Funding, Personnel, and Coordination

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Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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,

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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-

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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-

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×
Overview of Government Involvement in Preventive Intervention Research

Research and services related to the prevention of mental disorders occur across a diverse array of federal and state agencies. Often this is not recognized or acknowledged by the agencies. Table 12.6 lists the federal agencies that are involved, though to varying degrees, in

TABLE 12.6 Federal Agencies Involved in Preventive Intervention Research and/or Preventive Intervention Services Related to Mental Disorders

aFormerly under the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA).

bFormerly the Office for Substance Abuse Prevention (OSAP).

Department of Agriculture

Department of Defense

Department of Education

Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

Head Start Bureau

National Center on Child Abuse and Neglect

Public Health Service

Centers for Disease Control and Prevention

Health Resources and Services Administration

Maternal and Child Health Bureau

Indian Health Service

National Institutes of Health

National Center for Nursing Research

National Institute on Aging

National Institute on Alcohol Abuse and Alcoholisma

National Institute of Child Health and Human Development

National Institute on Drug Abusea

National Institute of Mental Healtha

Office of Disease Prevention

Office of Health Promotion and Disease Prevention

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Center for Substance Abuse Preventiona,b

Department of Housing and Urban Development

Department of Justice

Office of Juvenile Justice and Delinquency Prevention

Department of Transportation

Department of Veterans Affairs

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

preventive intervention research and/or services related to mental disorders. This compilation is based on direct contacts with agencies and reviews of agency program plans and annual reports and is arranged in alphabetical order.

The overall DHHS support for all types of prevention activities related to both physical and mental disorders in FY 1991 was $14,753,933,000 (DHHS, 1992). In Table 12.7 the funding levels for 3 of 23 priority areas—alcohol and other drugs, mental health and mental disorders, and violence and abusive behaviors—are given for DHHS agencies (DHHS, 1992). Unfortunately, these do not separate services and research.

The Maternal and Child Health Bureau within DHHS is an agency well-known for its services to women and their children. It is presented here as an example of an agency that is not well recognized as contributing to prevention of mental disorders. A careful review of its grants revealed otherwise (see Box 12.1).

Private Foundations

Many private foundations also support prevention services and research related to mental disorders. Some of the better-known examples include American Express Foundation, Ford Foundation, William T. Grant Foundation, Conrad N. Hilton, The J.M. Foundation, Henry Kaiser Family Foundation, Lilly Endowment, Inc., Meyer Memorial Trust, Annie E. Casey Foundation, The Robert Wood Johnson Foundation, the Carnegie Corporation, the W.K. Kellogg Foundation, The Pew Charitable Trusts, and the Colorado Trust.

Conclusions

Rational planning for the nation's prevention research agenda requires much more accurate monitoring and reporting of prevention activities related to mental disorders. The Computer Retrieval of Information on Scientific Projects (CRISP) system has resulted in incomplete and inaccurate data with extensive multiple counting of research projects. In 1991 DHHS reported expenditures of approximately $2 billion for prevention activities related to mental disorders and abuse of alcohol and other drugs. According to the draft ADAMHA report, the funding of prevention activities was substantial in 1991—$749,093,000. ADAMHA's $749 million is likely to be incorporated into DHHS's $2 billion, but it is not clear that they were using identical definitions of prevention activities. In contrast to both of these large figures, the total 1992 budget of the three Prevention Research Branches at NIMH, NIAAA,

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

TABLE 12.7 Department of Health and Human Services Agencies Reporting Prevention Activities in Priority Areas, 1991 (dollars)

 

Alcohol and Other Drugs

Mental Health and Mental Disorders

Violent and Abusive Behavior

Overall Prevention Budgeta

Public Health Service

       

Food and Drug Administration

6,500,000

0

0

669,100,000

Health Resources and Services Administration

2,331,000

690,000

319,000

1,113,211,000

Indian Health Service

69,747,000

25,462,000

0

706,000,000

Centers for Disease Control

2,600,000

0

5,600,000

1,134,116,000

National Institutes of Health

2,840,000

6,112,000

1,652,000

1,927,963,000

Alcohol, Drug Abuse, and Mental Health Administration

426,703,000

43,134,000

5,364,000

753,907,000

Agency for Health Care Policy and Research

382,000

1,455,000

63,000

45,195,000

Office of the Assistant Secretary for Health

0

0

0

46,148,000

 

———

———

———

———

Total Public Health Service

511,103,000

76,853,000

12,998,000

6,395,640,000

Health Care Financing Administration

190,000,000

1,216,000,000

0

7,546,600,000

Administration for Children and Families

49,372,000

1,235,000

29,250,000

811,693,000

 

———

———

———

———

Total resources reported in 1991 for prevention (DHHS)b

750,475,000

1,294,088,000

42,248,000

14,753,933,000

aThe overall prevention budget includes the three priority areas listed plus an additional 20 priority areas.

bEstimated.

SOURCE: Figures obtained from Prevention '91/'92: Federal Programs and Progress (DHHS, 1992).

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

BOX 12.1

Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB) is part of the Health Resources and Services Administration (HRSA) within the Public Health Service of the Department of Health and Human Services. In FY 1991, MCHB had a budget of approximately $637 million. Of this, $500 million was allocated for block grants to the states. The Maternal and Child Health Services Block Grant under Title V of the Social Security Act supports activities, through state block grants and project grants, to improve the health status of mothers and children.

Funds are used for the purpose of enabling states: (a) to assure mothers and children (particularly those with low income or with limited availability of health services) access to quality maternal and child health services; (b) to reduce infant mortality and the incidence of preventable diseases and handicapping conditions among children, to reduce the need for inpatient and long-term care services, to increase the number of children appropriately immunized and the number of low income children receiving health assessments and follow-up diagnostic and treatment services, and otherwise to promote the health of mothers and children (especially by providing preventive and primary care services for low income children, and prenatal, delivery, and postpartum care for low income mothers); (c) to provide rehabilitation services for blind and disabled individuals under age 16 receiving benefits under Title XVI of the Social Security Act; and (d) to provide services for locating, and for medical, surgical, corrective, and other services, and care for, and facilities for diagnosis, hospitalization, and aftercare for children with special health care needs or who are suffering from conditions leading to such status.

During the 1980s the MCHB state block grants were largely unregulated by the federal government. However, as a result of new legislation in 1989, the directing of the states' monies was shifted and placed under more federal control. This shift was made “to improve states ' planning, accountability, and targeting of federal funds to priority populations” (OBRA, 1989). Previously, the states only had to submit a report of intended expenditures to receive the block grant monies. Now, obtaining this money entails an application process, state and federal reporting requirements, and submission of annual reports for review, as well as several other provisions as outlined in the Omnibus Budget Reconciliation Act of 1989.

The remaining 1991 budget monies constitute the MCHB discretionary fund. The formula for this, which is set by Congress, is 15 percent of all appropriated state block grant funds plus an extra 12.75 percent of state block grant funds over $600 million. The discretionary monies are used for service demonstration programs, research, implementation programs, and training. Included within these monies are programs of special projects of regional and national significance (SPRANS), as well as Community Integrated Services Systems (CISS). Additionally, support is provided for emergency medical services for children, pediatrics AIDS health care demonstration projects, and Healthy Start (not the Hawaii Healthy Start program described in Chapter 7).

Every year, MCHB publishes the abstracts of the active projects supported with discretionary funding. A review of the 1991 book, which included 591

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

abstracts and an index, provided an overview of the breadth of the work done through MCHB. In 1991, $8 to $10 million was used for research.

Much of the discretionary work of MCHB is highly relevant to the issues of promotion of mental health and prevention of mental disorders. However, the agency does not conceptualize these issues in this way. The index of the 1991 book of abstracts does not include some of the main terms and definitions used in this report. For example, there is no mention of mental disorders, mental health, risk, risk reduction, mental health promotion, or universal/selective/ indicated preventive interventions. On the other hand, listings in the index do include substance abuse (101), alcohol (18), injury prevention (21), preventive health care (21), mother-child interaction (10), health promotion (9), child abuse (4), child neglect (12), behavioral disorders (3), behavioral problems (1), violence (7), and low birthweight (32). All of these issues are related to mental health and mental disorders, especially within a conceptual framework of risk reduction.

Many of the service demonstration projects, implementation projects, and research projects of MCHB are preventive in orientation, whereas others are more treatment oriented. However, the grants are not categorized according to this distinction. Using this committee's definitions, some grants were selective preventive interventions, and others were indicated preventive interventions.

Research grants clearly had been required to meet standards of methodological rigor, but the service demonstrations and implementation projects varied along a continuum of evaluation rigor. Although some approached high standards of design and evaluation, others provided “process evaluations” of questionable value.

MCHB has collaborated with other federal agencies and private foundations in its use of discretionary funds, including the former ADAMHA, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Administration for Children, Youth and Families. Two research projects that MCHB has co-funded with private foundations stand out as exemplary preventive interventions that demonstrate how preventive interventions can have effects on both physical and mental health. These are the Infant Health and Development Program, which was conducted at eight sites, and the Study of Home Visitation for Mothers and Children, in Memphis, Tennessee, which is a replication study to validate the findings of the previously completed Prenatal/ Early Infancy Project, in Elmira, New York, which also received MCHB support. (These programs are reviewed in more depth in Chapter 7 and Chapter 11.)

The ADAMHA Reorganization Act authorized the Health Resources and Services Administration under Title IV to make grants to provide services to children of substance abusers and families in which a member is a substance abuser. The services to children are to include periodic evaluation for developmental, psychological, and medical problems as well as preventive counseling services and counseling related to the witnessing of chronic violence. Evaluation of the effectiveness of these programs is to include assessment of the prevention of adverse health conditions in children of substance abusers. HRSA was also authorized under Title V to make grants for home visiting services for at-risk families. Services are to be targeted to pregnant women at risk of delivering infants with a health or developmental condition. Services are also to be provided to children under age 3 who are experiencing or are at risk of (1) health or developmental complications or (2) child abuse or neglect. Again, evaluation to determine effectiveness was stipulated in the act. Although support for these

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

services has not been appropriated, the act clearly has recognized the importance of HRSA's role in prevention of problems that are both physical and psychological. It would be beneficial—and not difficult —to employ rigorous methodological standards in these evaluations.

In light of the findings from this review, the committee makes the following suggestions:

  • MCHB should be recognized for the critical role it has had and should continue to have in the prevention of mental disorders. More research needs to be done on the effects of risk reduction during gestation, infancy, and early childhood, and on the possible long-term effects on the reduction of new cases of mental illness. MCHB has access to and acceptance from high-risk populations because of its programs to provide physical health care.

  • Efforts should be made to identify those projects that are related to a broad definition of mental health and mental disorders, using the conceptual framework of risk reduction.

  • Preventive interventions within the mental health/mental disorder spectrum should be differentiated from treatment and from maintenance. Preventive interventions should be categorized according to the universal/selective/ indicated classification scheme recommended in this report.

  • Research of the quality of the two illustrative preventive interventions, the Infant Health and Development Program and the Study of Home Visitation for Mothers and Children (formerly the Prenatal/Early Infancy Project), should be encouraged.

  • Evaluation of new projects should employ rigorous methodological standards.

and NIDA (all at that time part of ADAMHA) was $64,160,597. Expenditures at the PRBs included support for risk identification research, development of statistical methodology, training for identification and treatment of depression, alcohol treatment research, and other activities that, while worthy in their own right, are not preventive intervention research. Large preventive intervention demonstration projects were also included. While rigorous in their methodology, these have not been scaled up in size based on significant findings in prior pilot, confirmatory, and replication studies as recommended in Chapter 10.

In contrast to these findings, and using the definitions and guidelines developed in Chapter 2, Chapter 7, and Chapter 10 of this report, the committee's best estimate is that the federal government's expenditure for rigorous preventive intervention research specifically targeted toward the prevention of mental disorders is approximately $20 million per year.

For the reasons discussed in this chapter, it is difficult to precisely describe the current levels of expenditure by federal agencies. Nevertheless, this is the committee's best estimate of rigorous prevention research. Recommendations for increases in support (discussed in

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

Chapter 13) are derived from this estimate and the committee's analysis of the investment needed to enable the field of preventive intervention research on mental disorders to proceed.

PERSONNEL

Using multiple sources of information, the committee tried to determine the number of researchers working in the field of mental disorder preventive interventions. One source of data that the committee examined was the CRISP lists of grantees (1988 to 1992) for all three types of prevention (mental disorders, alcoholism, and drug addiction). The total number of grantees was 202. As discussed previously, there are many problems with CRISP information.

In late 1992 the Society for Prevention Research had 125 members. The aim of the society is to foster the scientific investigation of prevention issues. Because the initial issue that brought the society's organizers together was substance use prevention, the members are mostly from the substance abuse field, including alcoholism. In mid-1993 the National Association of Prevention Professionals and Advocates (NAPPA) had 524 members. The early focus of NAPPA was on alcohol and other drug abuse prevention, but it now includes social and health problems. Most of the membership is professional, but relatively few are researchers. The National Mental Health Association (NMHA) has a prevention constituency of 144, but how many of these are researchers is not known. Researchers who belong to NMHA are likely to have research grants and to belong to other research societies. Therefore they are likely to be identified through other sources. From FY 1985 through FY 1991, 112 researchers were funded by the NIMH PRB. Not all of them, however, were preventive intervention researchers, and some of them are no longer active in the prevention field.

Allowing for other researchers who may be funded by state agencies, universities, private foundations, and federal agencies not listed in CRISP, it is likely that there are no more than 500 researchers in the field of preventive interventions for mental disorders. The number who are fully trained to do the rigorous research described in Chapter 10 is much smaller than 500.

Probable Demand for Trained Prevention Researchers

Current and future budget constraints require that the proposed size of the training enterprise be congruent with the likely size of the research enterprise. Any proposal for training should be grounded in

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

projections of demand for personnel. The committee's projection of demand is based not only on its judgment that the conventional university-based research effort focused on preventive intervention trials should increase in size, but also on its expectation that high-quality evaluations will be required for prevention service programs that are carried out in community organizations. Evaluation is critical when programs developed in research settings are adopted for the community. It is also essential when programs are developed in the community and have not been tested in research trials. This need for evaluation substantially increases the need for trained experts; the stakes are very high in terms of the national resources to be invested in these broad-based programs, whether they are universal, selective, or indicated. Thus the committee proposes that professionals trained in preventive intervention research are needed in federal, state, and local departments of education, social service, and public health. Although it is difficult to be precise, the steady-state national requirement of trained personnel, from various disciplines, is certainly at least 1,000 people.

Educational Background of Current Researchers

Few, if any, current researchers in preventive intervention research have completed a formal training program designed to produce researchers in the prevention of mental disorders. The committee obtained data on the type of degree for 97 of the 223 CRISP grantees funded from 1988 through 1992. This information came from agencies and professional membership listings. Of the 97, 81 are Ph.D.s (most in psychology), 12 are M.D.s, and 4 are Ed.D.s. Other data provided by NIMH further confirmed that the field of preventive intervention research is composed mainly of psychologists. There are some physicians and sociologists and almost no nurses or social workers. The scarcity of researchers in these other disciplines is in part due to the lack of emphasis on research and on prevention in their training programs.

Prevention is not a discipline but an interdisciplinary field of research. Most current researchers were trained in their primary discipline and then learned their research skills as apprentices on a research team. Moreover, a substantial proportion of the current researchers in the field migrated to prevention research after working in other related areas of inquiry. Many prevention researchers only do prevention research part time. As with some other fields, such as health services research, prevention of mental disorder research is impeded by traditional academic departments within universities that do not reward applied interdisciplinary studies, especially when the payoff is some time in the

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
×

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.

Suggested Citation:"12 Infrastructure for Prevention: Funding, Personnel, and Coordination." Institute of Medicine. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press. doi: 10.17226/2139.
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The understanding of how to reduce risk factors for mental disorders has expanded remarkably as a result of recent scientific advances. This study, mandated by Congress, reviews those advances in the context of current research and provides a targeted definition of prevention and a conceptual framework that emphasizes risk reduction.

Highlighting opportunities for and barriers to interventions, the book draws on successful models for the prevention of cardiovascular disease, injuries, and smoking. In addition, it reviews the risk factors associated with Alzheimer's disease, schizophrenia, alcohol abuse and dependence, depressive disorders, and conduct disorders and evaluates current illustrative prevention programs.

The models and examination provide a framework for the design, application, and evaluation of interventions intended to prevent mental disorders and the transfer of knowledge about prevention from research to clinical practice. The book presents a focused research agenda, with recommendations on how to develop effective intervention programs, create a cadre of prevention researchers, and improve coordination among federal agencies.

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