13

Conclusions and Recommendations: An Agenda for the Next Decade

When President Roosevelt announced in 1937 that “one third of our nation are ill housed, ill clad, ill nourished,” our country was galvanized into action. Yet today, when careful population studies tell us that as many as one third of American adults will suffer a diagnosable mental disorder sometime in their life and that 20 percent have a mental disorder at any given time, there is little alarm. The Institute of Medicine's Committee on Prevention of Mental Disorders believes that strong action is warranted, and with this report it calls on the nation to mount a significant program to prevent mental disorders. Although research on the causes and treatment of mental disorders remains vitally important—and indeed major advances are leading to better lives for increasing numbers of people—much greater effort than ever before needs to be directed to prevention.

Public health experience has shown that when a critical mass of knowledge regarding a specific health problem accumulates and a core group of expert researchers have been identified, the time is ripe for launching a larger, coordinated research and training endeavor. The committee believes that such a moment has arrived for the field of mental health. Opportunities now exist to effectively exploit existing knowledge to launch a promising research agenda on the prevention of mental disorders. Therefore the committee strongly recommends that an enhanced research agenda to prevent mental disorders be initiated and supported across all relevant federal agencies, including, but not limited to, the Departments of Health and Human Services, Education, Justice, Labor, Defense, and



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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 13 Conclusions and Recommendations: An Agenda for the Next Decade When President Roosevelt announced in 1937 that “one third of our nation are ill housed, ill clad, ill nourished,” our country was galvanized into action. Yet today, when careful population studies tell us that as many as one third of American adults will suffer a diagnosable mental disorder sometime in their life and that 20 percent have a mental disorder at any given time, there is little alarm. The Institute of Medicine's Committee on Prevention of Mental Disorders believes that strong action is warranted, and with this report it calls on the nation to mount a significant program to prevent mental disorders. Although research on the causes and treatment of mental disorders remains vitally important—and indeed major advances are leading to better lives for increasing numbers of people—much greater effort than ever before needs to be directed to prevention. Public health experience has shown that when a critical mass of knowledge regarding a specific health problem accumulates and a core group of expert researchers have been identified, the time is ripe for launching a larger, coordinated research and training endeavor. The committee believes that such a moment has arrived for the field of mental health. Opportunities now exist to effectively exploit existing knowledge to launch a promising research agenda on the prevention of mental disorders. Therefore the committee strongly recommends that an enhanced research agenda to prevent mental disorders be initiated and supported across all relevant federal agencies, including, but not limited to, the Departments of Health and Human Services, Education, Justice, Labor, Defense, and

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Housing and Urban Development, as well as state governments, universities, and private foundations. This agenda should facilitate development in three major areas: Building the infrastructure to coordinate research and service programs and to train and support new investigators. Expanding the knowledge base for preventive interventions. Conducting well-evaluated preventive interventions. As previously stated, the committee's recommendations for funding of rigorous preventive intervention research are based on its best estimates of current efforts and its judgment of needed resources to create a robust federal research agenda. The committee finds the need for prevention of mental disorders so great and the current opportunities for success so abundant that it recommends an increased investment across all federal agencies over the next five years (1995 through 1999) to facilitate the development of these three major areas of the research agenda. It recommends increased support of $50.5 million per year for the next two years, $53 million in year three, and $61 million per year in years four and five. These are modest increases considering the magnitude of the problem of mental illness in this country, and Congress may decide that an even greater investment is warranted. Funding for the second five years should be recommended by a new coordinating body, such as a national scientific council on the prevention of mental disorders. The amount appropriated in year six should be no less than the amount of support in FY 1999. On the basis of positive results in the first five years, a considerably larger investment could be warranted during the second five years. The three major areas to be developed are recommended in conjunction with use of the definitions of interventions for mental disorders and of prevention research developed in this report. The term prevention is reserved for only those interventions that occur before the initial onset of a disorder. These preventive interventions can be further classified into universal, selective, and indicated types. The term prevention research refers only to preventive intervention research and is distinct from research that builds a broad scientific base for preventive interventions. BUILDING AN ENHANCED INFRASTRUCTURE FOR PREVENTIVE INTERVENTION RESEARCH Preventive intervention research for mental disorders cannot thrive without providing for its infrastructure. Two areas are particularly important for moving ahead—coordination and research training.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH The Coordination Role and Structure Coordination among federal agencies is needed for four reasons: (1) variation in the application of definitions has made it virtually impossible to assess the current activities and expenditures in preventive intervention research; (2) duplication of research activities and the lack of piggybacking of smaller projects onto larger ones contribute to waste of dollars and time, and, at the same time, gaps in research go undetected; (3) agencies conduct research or provide interventions for mental disorders (including addictions), educational disabilities, criminal behavior, and physical disorders as though these were separate conditions, whereas, more often than not, coexisting disorders or problems occur; and (4) agencies have different strengths; for example, some are better at applying rigorous research methodologies to intervention programs, whereas others are better at reaching out into communities and forging alliances. In arriving at its recommendations about coordination, the committee reviewed various alternatives. The decisions to be made include (1) how best to coordinate the various relevant activities, (2) where the coordination function should reside within the federal government, and (3) staffing and funding issues. The structure and function of the coordination mechanism are inextricably intertwined, so decisions 1 and 2 above cannot be readily separated. Staff and funding should be attached to the coordination mechanism wherever it is located. Four alternatives were considered regarding where the coordination function should reside. Although the committee does express a preference for coordination at the highest possible level, it believes that establishing a successful coordination mechanism across federal departments is more important than the details of where it is housed. Initially, the committee considered the model of putting a coordination role in one agency, such as the National Institute of Mental Health (NIMH) or the National Institutes of Health's (NIH) Office of Disease Prevention. Locating the coordination role in a single agency is a natural way to keep coordination close to the science, because the personnel in NIMH or the director's office at NIH are likely to be more closely connected to the scientific network than those higher in the government. Although single agencies have mediated coordination among other parts of the same department and even among branches of different executive departments in the past, the breadth and extent of the need for multiagency collaboration in this case make a single agency lead seem unrealistic. One possible exception is the Centers for Disease Control and Prevention (CDC), which has a public health mandate for

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH prevention activities and considerable experience in working collaboratively with federal, state, and local agencies. Coordination from an office within one department that serves as an umbrella over several relevant agencies is a second alternative. The Office of the Assistant Secretary for Health within the Department of Health and Human Services (DHHS) already contains an Office for Disease Prevention and Health Promotion. This office could be charged with forming a subcommittee or task group to focus specifically on the coordination of research aimed at preventing mental disorders and substance abuse. These preventive efforts share many features with other disorders already subject to coordination within this office, but the involvement of the criminal justice system, the educational system, child and spousal protective services, civilian and military family support services, and other nonmedical services necessarily encompasses activities in an even broader array of federal agencies. Many of these services are housed in entirely separate cabinet departments. The committee thus believes that coordination at the departmental level is preferable to coordination by a single agency (with the possible exception of CDC), but the nature of the problem may well necessitate a higher-level coordination mechanism. As a third alternative, the committee considered models developed within Congress, such as the Physician Payment Review Commission (PPRC) and the Prospective Payment Assessment Commission (PROPAC), for which appointments are made by an independent body—the Office of Technology Assessment. The question regarding these models is how well they would work in the prevention field, where many of the activities center on coordination of ongoing programs conducted within the executive branch. As a fourth alternative, the committee considered other successful models—the ongoing White House Conferences, various presidential commissions, and the Office of Science and Technology Policy (OSTP) —within the White House. OSTP was originally created by President Eisenhower to focus national attention on science; after being disbanded, it was reestablished by President Ford upon the recommendation of the National Academy of Sciences (1974). This model has three components: (1) an office having coordinating responsibility regarding national science policy, (2) an individual who serves as the President's science advisor, and (3) a council with expertise in a broad range of scientific matters. The advantages of having a coordination structure under the White House are that it is at a natural level for coordinating activities of different cabinet departments and that it places a premium on interagency cooperation, which the committee believes is an essential element.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH The committee thus leans toward the establishment of an overarching federal council, operated out of the White House Office of Science and Technology Policy or another coordinating office within the Executive Office of the President, to coordinate preventive intervention research. It recognizes that research and services related to the prevention of mental disorders have high relevance to the many other agendas and priorities of Congress and the President. These include the lack of high-quality education, deteriorating cities, drug problems, the lack of housing, poverty, and the lack of universal health care. Mental disorders contribute to these problems and vice versa; therefore the ultimate solutions must be broad in scope. Adequate staffing and resources are essential to successful coordination of prevention research regardless of where it is located in the federal government. Moreover, the quality of leadership and extent of commitment among agencies are often far more important than the precise location of a coordination office. Leadership and commitment cannot be fully controlled, no matter how careful the plans may be. The competence of the particular individuals chosen to lead the effort and the politics of the day often determine whether interagency coordination is truly successful or merely an effort that consumes staff time and wastes increasingly scarce federal dollars. Despite these caveats, the committee nonetheless believes that a coordinating committee at the highest possible level with adequate staffing is necessary to weave together disparate federal activities in many different departments. The committee strongly recommends that a mechanism be created to coordinate research and services on prevention of mental disorders across the federal departments. One model for accomplishing this would be the establishment of a national scientific council on the prevention of mental disorders by Congress and/or the President. Such an overarching federal council could be operated out of the White House Office of Science and Technology Policy or another coordinating office within the Executive Office of the President. This council should formulate policies regarding preventive intervention research, evaluation of prevention services, knowledge exchange, coordination of interagency research efforts, and training. Because prevention activities span different departments, the members of the council should be appointed after soliciting nominations from a wide constituency who are willing to use the definitions and rigorous methodological criteria developed in this report to foster policies that will reduce the onset of mental disorders and related problems. Members should include—as equal partners—ex-officio high-level representatives of relevant federal agencies, including but not limited to the Departments of

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Health and Human Services, Justice, Labor, Education, Defense, and Housing and Urban Development, as well as representatives from state agencies, private foundations, universities, and the public at large. A broad range of disciplines, including medicine (pediatrics, child psychiatry, psychiatry, primary care), psychology, nursing, social work, public health, sociology, and epidemiology, should be represented. The council should meet regularly to coordinate collaborative research across public and private agencies and should monitor the standards for rigorous methodological approaches to preventive intervention research. Terms on the council for nonfederal representatives should be limited. To provide ongoing executive leadership, the chair of the council should be appointed by the President. Other leadership positions could be selected from the nonfederal representatives. The council should have its own paid staff, including a coordinator with staff, who operates out of an office of prevention of mental disorders. The office should oversee and coordinate the daily operations of preventive intervention activities in all areas that are related to mental health across the federal government. The staff of the office should be responsible to the council. The council should report regularly, at least once a year, to the Congress and the President. The committee also strongly recommends that Congress encourage the establishment of offices for prevention of mental disorders at the state level. The current number of such offices is small even though the states have resources for prevention available to them through the state block grants. A mechanism to encourage the development of state offices would be a requirement attached to the block grants, and as health care reform is developed other possibilities may occur. The functions of these offices should be similar to those of the proposed national scientific council on the prevention of mental disorders. States that do establish such offices should, as a group, elect representatives to the national scientific council. Agencies must be required to identify their funded programs for the prevention of mental disorders, separately accounting for universal, selective, and indicated preventive interventions, using the definitions developed in this report. Congress should ask for separate accounting of these different kinds of preventive interventions when agencies report on the activities they support. The National Institute of Mental Health (NIMH), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA) should consider including prevention researchers with broad mental health perspectives on their national advisory councils. The prevention research field must produce more researchers of international stature who can serve on such advisory councils.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Mental health reimbursement from existing health insurance should be provided for preventive interventions that have proved effective under rigorous research standards such as those described in this report. Dissemination activities should receive much higher priority than they have in the past. Agencies should disseminate results of research trials as well as evaluations of preventive intervention service programs. Funding of research trials should be continued only when investigators demonstrate a good publication record (including theoretical formulations and data from research trials). Interagency research conferences should be encouraged. A federal clearinghouse on preventive interventions in the mental health field should be considered, either as part of the council's function or as a separately funded initiative. Research Training Training is an immediate and critical need in preventive intervention research. Congress and federal agencies should immediately take steps to develop and support the training of additional researchers who can develop new preventive intervention research trials as well as evaluate the effectiveness of current service projects. This training effort should include consortiums, seminars, fellowships, and research grants to attract existing researchers into prevention research, training programs for new investigators, and expansion of the training component of the specialized prevention research centers. Research training should be focused on two groups—mid-career scientists and postdoctoral students. Training for these groups should be developed simultaneously, but the expectation is that the training efforts for these groups will produce two waves of personnel. As an immediate strategy, training opportunities with adequate stipends should be developed to attract talented mid-career scientists from related fields, such as risk research, epidemiology, treatment effectiveness research, and research on prevention of physical illnesses, who seek to make the transition to research on prevention of mental disorders. This could be done through existing fellowships and career development awards and through the development of creative consortiums, seminars, and mentoring. All training should be tailored to the needs and schedules of these scientists. Such training could have a substantial impact on the number of personnel within three years if there is a simultaneous increase in the funds available for peer-reviewed research projects (RO1s). As a second strategy, training opportunities with sufficient stipends should be developed to attract talented postdoctoral-level trainees to preventive intervention research. Much more effort should be made to

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH attract trainees from a wide range of disciplines, including psychiatry, pediatrics, social work, nursing, public health, epidemiology, neuroscience, anthropology, and sociology, as well as psychology, which dominates the field today. If efforts to boost doctoral training begin concurrently with mid-career training, we might expect to see the benefits of an increased pool of researchers capable of securing their own research grants by year five of a 10-year plan. The number of institutional training programs focusing on preventive intervention research should be increased from 5 to 12 over the next five years, including one at every specialized prevention research center, known at NIMH as Preventive Intervention Research Centers (PIRCs), that is productive. Training of mid-career scientists and postdoctoral students should occur within every specialized prevention research center. To ensure that this happens, funding of specialized prevention research centers should be continued only when they demonstrate good track records in the production of published research and in the training of researchers capable of procuring their own research grants. In addition to the specialized prevention research centers, research training should be supported by federal agencies, schools of public health, and schools traditionally linked to service, such as social work, education, nursing, and medicine. Support for faculty within institutional training programs should be increased. Such support should increase the capacity of the faculty, program, and university to train preventive intervention researchers. A major effort should be made to encourage the prevention research training of minorities. Support should be offered to minority mental health research centers and other centers that focus on specific populations, such as low-income groups, the elderly, and minority groups. This would add more researchers to the field, but even more importantly, they would be researchers who specialize in populations with special needs. The proposed national scientific council on the prevention of mental disorders should reevaluate the training needs for preventive intervention research after the first five years. At that point the emphasis on mid-career scientists might be able to be decreased. If so, support for predoctoral training could be increased. An emphasis on postdoctoral training should be consistently high throughout the decade. Funding Coordination and training are the two most immediate and important needs in preventive intervention research on mental disorders (see

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 13.1 Recommendations for Federal Government Support Above 1993 Level of Support (dollars in millions)   1995 1996 1997 1998 1999 Infrastructure           Council/office/dissemination 2.0 2.0 2.0 2.0 2.0 Training 12.0 12.0 12.0 12.0 12.0 Knowledge Base Research           Risk and protective factor research (biological/psychosocial interaction) 6.5 6.5 6.5 6.5 6.5 Child epidemiological study 2.5 2.5 2.5 2.5 2.5 Population studies 5.0 5.0 5.0 5.0 5.0 Mental health promotion study 0.5 0.5 0 0 0 Prevention Research           Preventive intervention research projects 20.0 20.0 20.0 25.0 25.0 Preventive intervention research centers 2.0 2.0 5.0 8.0 8.0 Total Budget 50.5 50.5 53.0 61.0 61.0 NOTE: Figures are based on 1993 dollar amounts and are not adjusted for inflation. These recommendations for support are based on the committee 's best estimates of current efforts and its judgment of needed resources to create a robust preventive intervention research agenda for mental disorders across the federal government. Table 13.1). The national scientific council on the prevention of mental disorders and the office of prevention of mental disorders should have a combined budget of $1 million per year for five years. Dissemination activities should be budgeted at $1 million per year for five years. Support for training should be budgeted at $12 million above the current level for year one, and this level of funding should be maintained for each of the next four years. In the first few years, these researchers are needed for evaluating current prevention service projects; gradually, they also will be conducting original preventive intervention research projects. Stipends for mid-career scientists should be in the $60,000 to $120,000 range, plus travel expenses. Stipends for postdoctoral trainees should be in the $30,000 to $60,000 range, plus travel expenses. EXPANDING THE KNOWLEDGE BASE The committee believes, based on the review of literature for this report, that a viable research agenda for prevention of mental disorders rests on a firm stratum of health research in other fields. This knowledge base includes basic and applied research in the core sciences that is aimed at the causes and prevention of mental disorders. Included in this

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH knowledge base are neurosciences, genetics, epidemiology, psychiatry, behavioral sciences (including developmental psychopathology), and risk research. It also includes evidence and lessons from other fields of research, such as prevention of physical illness and treatment of mental disorders. Research to expand the knowledge base for preventive interventions should be continued. Knowledge base research should continue to be supported for all five disorders reviewed in this report, in addition to other mental disorders. Basic research is essential to the understanding of mental disorders. New funds for the development of other knowledge base areas and for preventive intervention research should not be taken from funds currently used to support basic science. The committee also recommends that support be increased for the three specific knowledge base areas outlined below. Support of basic research will ensure the quality and continuity of the existing research effort and attract new investigators to those fields. Support for research on potentially modifiable biological and psychosocial risk and protective factors for the onset of mental disorders should be increased. Priority should be given to research, regardless of the type of mental disorder, that illuminates the interaction of potentially modifiable biological and psychosocial risk and protective factors, rather than restricting the research to either biological or psychosocial factors. NIMH should support a series of prospective studies on well-defined general populations under the age of 18 to provide initial benchmark estimates of the prevalence and incidence of mental disorders and problem behaviors in this age group. These epidemiological investigations should be oriented toward diagnosis but also should record a range of symptomatology, so that future changes in the diagnostic system, or developmental changes in individuals, do not preclude understanding of the development of psychopathology throughout this age range and into adult life. These prospective studies also should be oriented toward identification of modifiable risk factors in this age group with the explicit goal of recommending modifiable targets for preventive interventions in the future. A population laboratory should be established with the capacity for conducting longitudinal studies over the entire life span in order to generate understanding as to how risk factors and developmental transitions combine to influence the development of psychopathology. The primary goal of this laboratory should be the enhancement of knowledge for prevention and the development of new knowledge for the implementation of preventive intervention trials. Special attention should be paid to developmental transitions, such as childhood to adolescence, adolescence to adult-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH hood, entry into marriage, and loss of a spouse; precursor signs and symptoms, prodromal periods, age periods just prior to when a specific mental disorder is most likely to occur; and the effects of race, ethnicity, and gender. Well-designed preventive intervention research trials might be conducted with these populations during the follow-up, as long as the goal of obtaining benchmark estimates of epidemiological data, especially in regard to developmental transitions, is not threatened. The population laboratory could be established as a branch in the intramural program of NIMH, although there are advantages to making it a multiagency project funded through agreements among DHHS agencies such as the Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Administration (SAMHSA), National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute of Mental Health (NIMH), National Institute of Child Health and Human Development (NICHD), and Maternal and Child Health Bureau (MCHB), and departments such as the Departments of Justice, Education, and Defense. It could also be established as a unit outside the federal government funded through a special mechanism. An extragovernmental advisory panel, including experts in epidemiology, psychopathology, and prevention, should be formed to provide continuing scientific oversight to the population laboratory. Data from investigations of the population laboratory should be made available in anonymous form in a regular and timely fashion. Whenever possible, research proposals relevant to the knowledge base for preventive interventions should explicitly state this connection, such as identification of potentially modifiable risk factors and possible avenues for preventive interventions. This requirement should be applied across all federal agencies, and especially to research proposals funded from the additional support recommended by this committee. This clarification of relevance to prevention will help decrease confusion regarding definitions of prevention research and lead to findings relevant to preventive interventions. Treatment intervention research conducted under rigorous methodological standards that is directly relevant to preventive intervention research should continue to be supported—but not from the prevention research budget. The criteria for “direct relevance” should be reviewed by prevention researchers. Collaboration between treatment researchers and prevention researchers should be fostered. Principles from treatment research can and should be borrowed for use in prevention. Specialty areas in treatment research that are likely to yield payoffs for preventive intervention research include clinical psychopharmacology, cognitive-behavior therapy, and applied behavior analysis.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Research should continue to be supported to determine which risk and protective factors are similar and which ones are different for treatment and prevention of a variety of mental disorders. Identifying potentially modifiable factors that are unique to first onset of a disorder increases possibilities for prevention. Research should be supported to study the effects of social environments, such as families, peers, neighborhoods, and communities, on the individual and the effects of context on the onset of various mental disorders. Researchers working on relevant research in the core sciences should be encouraged to participate in activities such as forums and colloquia with preventive intervention researchers. A comprehensive, descriptive inventory of the activities in which the public engages to promote psychological well-being and mental health should be developed and supported. This catalog of mental health promotion activities is expected to be substantial. Preliminary efforts should also be made to craft outcome criteria for these activities that could be used in rigorous evaluations down the road. Funding The committee recommends that $6.5 million be budgeted each year for the next five years for risk research on the complex interaction between biological and psychosocial risk and protective factors. This would augment the research base for those mental disorders furthest along the continuum in the understanding of etiology, emphasizing the identification of malleable risk factors that would augur well for further preventive intervention research. A child epidemiological study should be budgeted at a minimum of $2.5 million per year over the next five years, and a population laboratory should be budgeted at $5 million per year over the next five years. Over a two-year period, $1 million should be allocated to catalog mental health promotion activities and to craft outcome criteria. CONDUCTING WELL-EVALUATED INTERVENTIONS The knowledge base for some mental disorders is now advanced enough that preventive intervention research programs, targeted at risk factors for these disorders, can rest on sound conceptual and empirical foundations. Increased methodological rigor in all research trials, demonstration projects, and service program evaluations should be required. Wherever

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH possible, the standards developed in this report, including hypothesis-driven randomized controlled trials and assessment of multiple outcome measures over time, should be instituted. The concept of risk reduction, including the strengthening of protective factors, should be used as the best available theoretical model for guiding interventions to prevent the onset of mental disorders. Other models for preventive interventions should continue to be explored; for example, as more becomes known about the mechanisms that link the presence of causal risk factors and absence of protective factors to the initial onset of symptoms, the possibilities for intervention may be increased. Universal preventive interventions should continue to be supported in the areas of prenatal care, immunization, safety standards such as the use of seat belts and helmets, and control of the availability of alcohol. These programs decrease brain injury and mental retardation, which are conditions associated with mental disorders. Although the main benefit of these interventions is the prevention of physical illness or injury, they may reduce the incidence of mental disorders as well. More evaluation is needed to assess their impact on mental disorders. Research on selective and indicated interventions targeting high-risk groups and individuals should be given high priority. Many of the programs described in this report are selective preventive intervention research programs, targeting multiple risk factors including poverty, job loss, caregiver burden, bereavement, medical problems, divorce, peer rejection, academic failure, and family conflict. These programs provide an impressive base for more rigorous research trials with larger samples. Priority should be given to preventive intervention research proposals that address well-validated clusters of biological and psychosocial risk and protective factors within a developmental life-span framework. Trials should measure short- and long-term outcomes for targeted disorders and should continue past the average age of onset. Sample size should be adequate for determining the validity of outcome measures. Increased attention should be given to preventive intervention research that addresses the overlap between physical and mental illness. For example, prevention trials with primary care populations should include examination of effects on physical well-being, use of health care (which at times may mean increased use), and social functioning. Research support should be developed in two waves over the next decade, initially focusing primarily on increasing research grant support for individual investigators and later on increasing support for specialized prevention research centers throughout the appropriate federal agencies. This strategy is based on the principle of building a prevention science from the ground up, rather than the top down. Individual investigators should compete for

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH research grant support. As their academic track record becomes established, they should be encouraged to increase the size and scope of their trials and join with other solid investigators to form preventive intervention research centers. In the first wave, lasting five years, there should be a substantial increase in the funds available for peer-reviewed research projects. Preventive intervention research programs should be supported for any mental disorder for which there is well-validated evidence of risk factors that appear to be modifiable. After five years, with the impact of new mid-career researchers joining the field and evidence from five years of research programs, a review should be made of the evidence. It is highly likely that several other preventive intervention research centers could be warranted at that time. Research grant support should not decrease at this time. Research on sequential preventive interventions aimed at multiple risks in infancy, early childhood, and elementary school age to prevent onset of multiple behavioral problems and mental disorders should be increased immediately and substantially. This should include a large number of new research grants and at least one new specialized prevention research center. The knowledge base regarding multiple risk factors in infancy and childhood interacting in complex causal chains and resulting in multiple disorders is extensive. Data on the direct linkage to specific disorders that emerge in adolescence and adulthood are becoming available. Many rigorously designed preventive intervention programs document impacts on risk and protective factors that are likely to reduce incidence rates of mental disorders. Addressing clusters of risk and protective factors increases the chances of preventing multiple disorders, especially major depressive disorder and conduct disorder. A number of separate randomized controlled trials have demonstrated the efficacy, and in some studies the effectiveness, of specific preventive interventions across development from the prenatal period through adolescence in reducing risk factors and enhancing protective factors. These should now be combined and delivered in sequence to high-risk populations. The interventions should include high-quality prenatal care, childhood immunizations, home visiting and high-quality day care (such as the Prenatal/Early Infancy Project and the Infant Health and Development Program), high-quality preschool (such as the Perry Preschool Program), parenting training, and enhancement of social competence and academic performance. High priority should be given to interagency sponsorship of this research, including the specialized prevention research centers. The Department of Health and Human Services (including the Maternal and Child Health Bureau (MCHB), National Institute of Child Health and Human Development

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH (NICHD), Administration on Children, Youth, and Families (ACYF), Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institute of Mental Health (NIMH)) and the Departments of Education, Justice, and Defense might be interested in sponsoring such research. Research on preventive interventions aimed at major depressive disorder should be increased immediately and substantially. This should include a large number of new research grants and at least one new specialized prevention research center. The knowledge base in this area is extensive, and promising preventive interventions have been empirically tested across the life span. Research to prevent depressive disorders should be more focused on preventing co-morbid mental disorders than it has been in the past. Also, outcomes often extend beyond traditional boundaries of mental disorders. For example, prevention of depression has strong implications for reducing suicides, lost work productivity, and physical disorders. High priority should be given to interagency agreements for research projects and specialized prevention research centers. Gradually over the next five years, other new specialized prevention research centers should be initiated to focus on depression and co-occurring conditions. Links between these new centers and other research sites are essential, and monies should be set aside to provide for ongoing collaboration. Research on preventive interventions aimed at alcohol abuse should be increased immediately. The knowledge base is extensive, and promising preventive interventions have been empirically tested. A less categorical approach to alcohol abuse preventive intervention research is needed. Coexisting illnesses, such as depressive disorders and physical disorders, must be carefully studied. Prevention of alcohol abuse has strong implications for reducing drug abuse, spouse and child maltreatment, and physical injury. The outcomes of preventive interventions on these problems also should be considered. For alcohol abuse, it may be best to target children and young adolescents to delay the initiation of alcohol use. Support for pilot and confirmatory preventive intervention trials should be increased for conduct disorder. Priority should be given to research that addresses multiple risk factors for young children with early onset of aggressiveness, including parental psychopathology, poverty, and neurodevelopmental deficits in the child. Research should be supported on alternative forms of intervention for the caregivers and family members of individuals with mental disorders, especially Alzheimer's disease and schizophrenia, to prevent the onset of stress-induced disorders among these caregivers.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Over the next decade, as new specialized prevention research centers are initiated, priority should be given to those that are sponsored through interagency agreement. In addition to the National Institute of Mental Health (NIMH), National Institute on Alcohol Abuse and Alcoholism (NIAAA), and National Institute on Drug Abuse (NIDA), other federal agencies, such as those in the Departments of Justice, Education, and Defense should be encouraged to become involved. Over the next 10 years, in addition to the new centers focusing on multiple childhood risks and depressive disorders, specialized prevention research centers could be developed for other risk factors or disorders if a review of the evidence suggests that such action is warranted. Knowledge base research at the specialized prevention research centers should be supported by new research grants (RO1s) that do not use preventive intervention research dollars. Specialized prevention research centers provide the structure, the personnel, and the study populations that could be used to increase the knowledge base for prevention through risk research and epidemiological studies as well as for increasing knowledge about preventive intervention research programs. When these two areas of research are combined in the same center, the definition of prevention research will be especially important. Dissemination mechanisms, including publication in peer-reviewed journals, and knowledge exchange opportunities with other researchers and with representatives from the community should be mandated as part of the mission of each specialized prevention research center. The preventive intervention research cycle as described in this report should be used as a conceptual model for designing, conducting, and analyzing research programs. Preventive intervention research should proceed from pilot studies to confirmatory and replication trials to large-scale field trials and finally be transferred into the community as service programs with rigorous evaluation. Increased attention to cultural diversity, ethical considerations, and benefit-cost and cost-effectiveness analyses should be an essential component of preventive intervention research. Community involvement should be increased to help identify disorders and problems that merit research and to support preventive intervention research programs. The committee believes strongly that the long-term interests of communities throughout the nation are best served if prevention services are based on well-crafted and thoroughly evaluated trial programs. Community groups that hope for the best long-term outcomes need to express an increased willingness to have service projects more rigorously evaluated and to bring promising prevention programs into the research cycle for a more complete analysis of efficacy and effectiveness.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Funding Preventive intervention research (excluding the specialized prevention research centers) should be budgeted at $20 million above the FY 1993 level of support in years one, two, and three, with an additional $5 million (from $20 million to $25 million) in year four and year five. Support for new specialized prevention research centers is budgeted at $2 million per year in years one and two, $5 million in year three, and $8 million per year in years four and five. (The NIMH PIRCs receive, on average, $500,000 for core support per year.) Some of this support could come from reallocation and more prudent use of federal resources that currently are available for prevention in a broad sense. For example, huge demonstration projects are rarely warranted; scaling up from confirmatory and replication trials to large-scale field trials is a more cautious and constructive use of resources. Finding out the effectiveness of programs before they are widely disseminated is likely to save money in the long term. The support that is requested in this report is not necessarily new money, but it is new for the field of preventive intervention research for mental disorders. Much of the support should come from a wide array of federal agencies already supporting prevention services that currently lack rigorous evaluation. A FINAL WORD There could be no wiser investment in our country than a commitment to foster the prevention of mental disorders and the promotion of mental health through rigorous research with the highest of methodological standards. Such a commitment would yield the potential for healthier lives for countless individuals and the general advancement of the nation's well-being. Even with the support of the federal government, the effort will not be easy. There will be no “magic bullet.” No single prevention strategy or method of changing people's life-style, behavior, or environment will work across the broad range of risk factors and mental disorders that will be encountered. A program designed to prevent one public health problem will not exactly fit the needs and goals of another. Dedication to prevention service programs will not necessarily bring success without a corresponding commitment to rigorous evaluation to determine the effectiveness of these services. No single agency can accomplish the task outlined above. Overall, the effort will require the cooperation of numerous federal, state, and local agencies, universities, foundations, researchers, and communities.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Hardly a family in America has been untouched by mental illness. The need for effective preventive intervention programs is clear. It is equally clear that to obtain such programs we need to make a national commitment to rigorous research and increased support for the infrastructure to make that research possible. REFERENCES NAS (National Academy of Sciences). ( 1974) Science and Technology in Presidential Policymaking. Report of the ad hoc Committee on Science and Technology. Washington, DC: National Academy of Sciences. Roosevelt, F. D. ( 1937) Second Inaugural Address, January 20.