Provided by the National Institute of Mental Health
The National Institute of Mental Health (NIMH)
develops and provides research information that will help people with mental
illness get the best possible care. Mental health services research integrates
research, practice, and policy to improve treatment and services for people with
mental illness. Grounded in "real-world" settings, it looks at patients,
providers, managed care, and state mental health systems. New knowledge gained
through research leads to improved public mental health in meaningful and
measurable ways.
Health services research examines the effects of social factors, financing
systems, organizational procedures, health technologies, and personal behaviors
on quality, cost, and access to health care, and ultimately, our health and
well-being. Research involves individuals, families, organizations,
institutions, communities, and populations. It may encompass academic
institutions, large state-wide service systems, and methods of "front-line"
clinical care.
Mental health services research looks at how traits of individuals, their
families, and social and cultural environments affect whether, where, and when
people will seek care, the types of care chosen or provided, what happens during
care, and outcomes. Social, cultural, and psychological characteristics of
providers and their interaction with patients are also considered.
Services research takes into account the economic, social, political, and
cultural environments in which services are delivered. This information affects
the organization, financing, management, delivery, and access to services, as
well as the course, cost, and outcomes of care. Translating scientific
breakthroughs into policies and procedures of clinical practice is an urgent,
essential, and achievable task. A report by the NIMH National Advisory Mental
Health Council, Bridging Science and Service, established that the Institute's
research must be useful and practical for people with mental illnesses,
clinicians, purchasers, and policy makers. The report recommended that NIMH
expand efficacy, effectiveness, practice, and systems research in order to
foster research across fields and speed the dissemination of important
findings.1
Visit the following link for more information about NIMH.
The NIMH Services Research Program
NIMH services research is housed primarily in the Division of Services and
Intervention Research.2 Research addresses services for the seriously mentally
ill; the effectiveness of public, private, and community-based care; the
economics and financing of mental health services, such as the impact of
insurance design and the costs and benefits of delivery systems; care quality
that examines treatment guidelines and outcomes; research methods; training; and
the social and cultural contexts of mental health care treatment, acceptance,
and delivery.
With some 280 grants in the portfolio, 10 of the programs include research
centers and training grants. Given the breadth of services research, the
Division of Mental Disorders, Behavioral Research, and AIDS (DMDBA) also
supports studies. The Center for Mental Health Research on AIDS services
portfolio has relevant programs in adherence, stigma, and health behavior spread
throughout various branches. Services research ranges from population-specific
initiatives involving childhood and adolescence, primary care, HIV and AIDS,
financing, and rural research to primary care, dissemination, and implementation
studies to improve clinical practice.
Examining managed care systems and access barriers to treatment is part of the
mental health services research agenda. Studying financing among employers,
insurers, and patients can affect whether treatments for illnesses are
available, who receives them, and the costs and quality of care. Sixty NIMH
studies contributed to the research base for evaluating mental health parity.
Breadth of NIMH Services Research
Child & Adolescent
Primary Care
Quality of Care & Outcomes
Financing & Managed Care
Systems Research
Sociocultural
Research Methods
Clinical Epidemiology
Dissemination Research
Disablement & Functioning
Interventions That Work
Many who are discharged from psychiatric inpatient facilities need assistance in
community settings. Continued medication, rehabilitation and vocational
assistance, and social support are of critical importance to help ensure
successful treatment. Services should be flexible and adaptable to needs,
preferences, and expectations.
For more than two decades, researchers have been working to develop and refine
models that will provide the care people need, but not rob them of
self-determination. One successful model, the Program for Assertive Community
Treatment (PACT), was designed to engage the client and provide services in
client-based settings with multidisciplinary teams and individual care plans.
Assertive community treatment (ACT) assists people most seriously disabled by
their mental illness�whether schizophrenia, bipolar disorder, or depression,
with or without co-occurring substance abuse�and are most at risk for
rehospitalization. The treatment method was devised to provide support for
people with limited problem-solving skills whose symptoms worsen rapidly when
they are under stress.
Those receiving ACT services have fewer days in the hospital; for people with a
history of chronic hospitalization, ACT is also cost effective. Some studies
show gains in quality of life and function. As a result of that evidence, the
director of the Health Care Financing Administration, renamed the Centers for
Medicare and Medicaid Services, advised state Medicaid directors to support
assertive community treatment programs of the Schizophrenia Patient Outcomes
Research Team (PORT) funded by NIMH and the Agency for Health Care Policy and
Research.
Care for people with severe mental disorders in community settings will continue
to be a challenge for those providing care or organizing systems that respond to
need. The research investment in PACT and other community-based approaches has
produced knowledge on setting up programs that can reduce hospitalization and
address the needs of clients living in the community.
Infrastructure Development
The initiatives are setting standards for scientific rigor and relevance. A new
grant is focusing on infrastructure development in "real-world" settings with a
training program to facilitate collaborative clinical research and team building
among clinicians and investigators.
A family services agency in New York City is partnering with 16 clinical sites
and an academic institution to improve mental health care and study important
research questions on child trauma and posttraumatic stress disorder (PTSD). An
infrastructure will be created to conduct studies of trauma screening and
treatment and to evaluate the system's ability to support the collaborative
research. The project will assess screening methods for childhood
victimization/trauma history in a large clinical service delivery system and
compare the efficacy of treatment for children and youths with PTSD to usual
care in a complex clinical service delivery system.3
Another grant aims to develop a sustainable mental health research
infrastructure to support clinical trials and effectiveness studies on the
detection, diagnosis, treatment, and prevention of mental disorders in
incarcerated adults. The Center for Correctional Mental Health Services Research
is a collaboration between the State of Connecticut Department of Correction,
Correctional Managed Health Care, and the University of Connecticut Health
Center. The initial research project will examine the effectiveness of a
validated treatment approach, the Texas Implementation of Medication Algorithm,
when it is modified and applied in a correctional setting. TIMA is an
evidence-based protocol for diagnosis, clinical case management, and
psychoeducation. Bipolar disorder was selected as the target illness because of
its prevalence and adverse impact on clinical and behavioral management in
correctional settings, as well as on readjustment and recidivism after reentry
in the community.4
Now-or-Never Research
Another type of grant encourages research to take place in "real time," in other
words, not coinciding with the normal NIH grant cycle. It enables researchers to
take advantage of now-or-never opportunities. If someone is going to make a
major change in a health care system on July 1, for example, researchers have an
opportunity to study that change and expedite a grant submission for the funding
cycle.
A proposed time-sensitive study of 488 homeless children in 300 families will
supply important information on how providing services and housing for homeless
families affects the mental health and behavior of homeless children over a
15-month period. The parent grant, funded by the Substance Abuse and Mental
Health Services Administration, focuses on the outcomes of mothers. With funds
to supplement this clinical trial, researchers will study the children, who may
be major beneficiaries.
By working with mothers, teachers/caregivers, and the children themselves, NIMH
researchers suggest that interventions may lead to lower levels of neighborhood
and environmental stressors, increased family support, and changes in mothers,
which in turn result in better parenting and services to children. Because of
this research, the county where the study is taking place has agreed to base
future decisions on organizing services.5
Improved Data on Family Intervention Research
Another study is an enhancement of a statewide effectiveness trial using a
home-based family preservation model for families who are at risk for child
neglect. Previous studies have shown modest behavioral changes and reduced
maltreatment recidivism. The proposed study would establish a data collection
system for existing state-funded home-based service agencies serving over 1,200
new families annually. Independent data collectors will test the importance of
intervention and collect post-treatment follow-up information to evaluate
gains.6
A Call for Innovation
A new announcement, "From Intervention Development to Services Research," aims
to encourage research on developing or pilot testing new or adapted
interventions; pilot testing interventions that demonstrate efficacy in broader
scale effectiveness trials; or on innovative services research requiring
preliminary testing or development. It provides resources to evaluate the
feasibility, acceptability, and safety of novel approaches to improving mental
health, modifying health risk behavior, and obtaining data needed for a larger
scale intervention or services study.7
In another announcement, NIMH and the Substance Abuse and Mental Health Services
Administration (SAMHSA) are partners in supporting evidence-based mental health
treatment practices in state mental health systems. NIMH is funding states that
determine the most effective ways to implement evidence-based practices in state
clinical practices; SAMHSA aims to provide direct support to states and
localities committed to adopting these practices.8
Partnerships, both within the federal government and beyond, are enhancing
research opportunities in the field. The Center for Medicare and Medicaid
Services (CMS), formerly the Health Care Financing Administration, has a large
quality improvement program using peer review organizations. Last year CMS
funded two projects in mental health. One program is looking at improving
screening for depression and another is studying care for people who have just
had heart attacks.
Other grants include:
Helping homeless men transition from hospital to the community.
This controlled study involves a Critical Time Intervention (CTI) for men and
women with severe mental illness during the transition from psychiatric hospital
to community care. The grant's primary aim is to diminish homelessness. Suicidal
thinking and behavior, violence toward others, and psychiatric rehospitalization
may also decrease. A key aspect of CTI is that staff who have established
relationships with patients during their institutional stay continue to work
with them during the post-discharge phase of the intervention.
CTI does not replace community treatment and supports, but complements available
services. CTI has demonstrated effectiveness with severely mentally ill men
following discharge from psychiatric care in a shelter institution to community
care. State officials write that if this program is successful, they will not
only implement it in their state, but will also reimburse it.9
The labor force, outreach, and treatment for depression.
With this grant, five large employers will screen tens of thousands of people
for depression. An effectiveness study will evaluate the impact of depression
outreach treatment on work-related behaviors. Researchers will make detailed
assessments of sickness absence, job-related accidents, work quantity and
quality, relationships, and job turnover. Those with the disorder will be in a
number of intervention programs. Cost benefit analysis will estimate the net
benefit of the program to employers.
Participating companies are American Airlines, Delta Airlines, the Massachusetts
State Employees Association, Northeast Utilities, and Raytheon. The program aims
to show employers that depression interventions are investment opportunities
with positive returns. Regional business groups on health and behavioral health
management consultants will work with researchers to create purchaser demand for
more depression treatment. This rapid and widespread dissemination will augment
the knowledge base of treatment effectiveness in an important "real-world"
setting.10
Improving Hispanic retention in antidepressant therapy.
A pilot study with depressed, culturally traditional Hispanics entering
antidepressant therapy suggests that cultural differences in patients' and
psychiatrists' expectations and concerns about treatment produce ambivalence
about taking medication or following physician instructions, which in turn
interferes with retention. The association between ambivalence about treatment
and dropout is predicted by stages that individuals experience during behavioral
change, a model that has not been empirically tested in Hispanics. This study
will yield pilot data on stages of behavioral change using a brief, effective
form of psychotherapy that targets ambivalence about treatment and on enhanced
retention of Hispanics in antidepressant therapy.
The goal is a culturally compatible intervention for psychiatrists in outpatient
pharmacological practice to increase retention of Hispanics with major
depressive disorder (MDD). Hispanic dropout from medication therapy for MDD is
two to three times the rate of non-Hispanic whites. Mental health treatment in
general is lowest among less acculturated, migrant Hispanics, even after
controlling for socioeconomic factors and psychiatric diagnosis, suggesting that
cultural factors are causes.11
American Indian and Alaska Native mental health research.
The University of Colorado Health Sciences Center has obtained support to
continue the highest quality research on the mental health of these special
populations. Research program and training opportunities address assessment,
epidemiology, and prevention of psychological dysfunction and major mental
illness among American Indians and Alaska Natives. The program aims to carry out
interdisciplinary research with emphasis on assessing dysfunction and major
mental illness among children, adolescents, and adults; service use among the
Indian population at large and within service settings, as well as gauging
outcomes of mental health services; the development, adaptation, implementation,
and evaluation of preventive intervention programs for children and youth;
structuring training as an integral part of the research program; and
disseminating results to guide the design, conduct and interpretation of future
mental health services in Alaska Native and American Indian communities. The
project will assist individuals and organizations to plan and implement mental
health research; continue to enhance the growing body of knowledge on mental
health and mental illness among these populations; and serve as a catalyst for
both programmatic and theoretical research.12
Medical practice patterns involving children with autism.
Clinical studies are addressing the safety and effectiveness of treatment and
rehabilitation interventions for children with autism or pervasive developmental
disorders. This multisite study examines the structure, utilization, and
expenditures for the care and treatment of autism. The three-year study will
identify services accessed by families with autistic children in different age
groups. The work will provide information to clinical researchers and
policymakers on which treatments are used, by whom, treatment combinations, and
circumstances under which they apply. Research results can inform clinical
trials and future projects, which may involve multiple medical, educational, and
behavioral treatments, as well as complementary and alternative treatments. This
first grant for the services portfolio in autism received funding recently.13
Fostering collaboration between mental health and criminal justice.
This Development Research Centers grant explains symptoms and treatment of
severe mental illness in minor offenders to the criminal justice staff. By
establishing the Mental Health Services and Criminal Justice Research Center,
the program focuses on mental health services issues that arise when people with
mental illness encounter the criminal justice system. A multi-disciplinary team
will be in a borderless research environment that includes researchers and sites
located around the country. The emphasis is on the individual with mental
illness, how that person comes to the attention of the criminal justice (CJ)
system, and the system's response to the person's illness as he or she moves
from court to jail/prison to the community. Understanding this dynamic is
central to developing prevention strategies. Research will address
identification and evaluation of mental illness, its treatment inside the jail
and in the post release period, and the policy initiatives and innovations that
impact the CJ system's response to mental illness.14
A business research grant offers a two-day curriculum for professionals working
with adult offenders with co-occurring disorders. It aims to improve mental
health and substance abuse services both within the criminal justice systems and
during and after community reentry. Addressing the interface between substance
abuse, mental health and criminal justice, the program aims to develop ongoing
collaborative implementation plans. The five modules include: Overview and
Mapping the System, Screening and Assessment, Treatment Issues and Strategies,
Systems Integration, and Blueprint for Action. Cultural competence and the
special needs of women are included. Case study materials include examples
appropriate for both institutional and community settings.15
Research Goals, Direction
In April 2002 NIMH conducted a workshop entitled "Evidence in Mental Health
Services Research: What Types, How Much, and Then What?"16 to stimulate interest
in the field and funding projects. The conference addressed types of evidence
needed; methods to acquire, rank, and quantify it; and how best to broadcast and
use the evidence we have. Experts from the mental health community and related
fields presented research on mental health policy and management, innovations in
trials, mental disorders and work functioning, using sociocultural research,
primary care interventions, mental health disparities among underserved
populations, diagnostic and service use, cost versus care, and attitudes toward
stigma.
A large task facing the field of mental health services research is determining
the best ways to disseminate information on effective treatments and services in
diverse settings to improve care for those with mental disorders. The workshop
focused on the challenge of weaving together research, practice, and policy to
improve care. It established goals to promote interaction between practitioners,
researchers, policymakers, and consumers regarding evidence in mental health
services research. Mental health services research aims to:
present innovative conceptual and theoretical models for considering evidence
and its use in mental health services research;
propose alternative methodologies, especially from traditionally underutilized
disciplines, to address the evidence questions above;
present research findings from successful and unsuccessful attempts to move
evidence into real world settings;
promote interaction between practitioners, researchers, policymakers, and
consumers regarding research on evidence in mental health services research;
link trainees with more seasoned researchers; and
promote collaborations between mental health services researchers and other less
utilized research disciplines.17
Senator William Frist, M.D., called for an improved NIH framework in an
editorial in the Journal of the American Medical Association.18 "Greater efforts
are needed to help research discoveries into practice and apply them to
patients," he wrote. Senator Frist reinforced the services research vision of
translating scientific knowledge into improved public health. Mental health
services research in communities will ultimately benefit medical practice and
patient care. A broadened NIH framework will translate scientific knowledge into
practice by incorporating advancements, fostering partnerships, and increasing
quality care for people with mental disorders.
Services research aims to inform the provision of consistent quality care across
all settings for all people who suffer from mental disorders and their loved
ones, and to improve all outcomes, especially functioning and reintegration.
The Broad NIMH Research Program
NIMH supports and conducts a broad-based, multidisciplinary program of
scientific inquiry aimed at improving the diagnosis, prevention, and treatment
of mental disorders in people of all ages. Increasingly the public, as well as
health care professionals, are recognizing these disorders as real and treatable
medical illnesses of the brain. Still, there is a need for more research that
examines in greater depth the relationships among genetic, behavioral,
developmental, social, and other factors to find the causes of these illnesses.
NIMH is meeting this need through a series of research initiatives.
NIMH Human Genetics Initiative
This project has compiled a large repository of clinical information and DNA
obtained from families affected by schizophrenia, bipolar disorder, autism,
Alzheimer's disease, and other mental disorders. Qualified scientists are given
access to these data and genetic materials in order to characterize the genetic
bases of mental disorders.
Neuroinformatics: Human Brain Project
This federal effort is using state-of-the-art computer science technologies to
organize the immense amount of data being generated through neuroscience and
related disciplines, and to make this information readily accessible through the
World Wide Web for simultaneous study by interested investigators. Because the
scope of the Human Brain Project extends to all facets of brain and behavioral
research and includes a range of technology sciences, this initiative is
sponsored, in a coordinated fashion, by fifteen federal organizations across
four federal agencies: the National Institutes of Health, National Aeronautics
and Space Administration, National Science Foundation, and U.S. Department of
Energy.
Prevention Research Initiative
Prevention research can be broadly characterized as seeking to understand the
development and expression of mental illness throughout the course of life so
that appropriate interventions can be designed and applied in order to prevent
mental disorders and promote mental health. Advances in biomedical, behavioral,
and cognitive sciences led NIMH to formulate a plan, Priorities for Prevention
Research at NIMH, which marries these sciences to prevention efforts. Focusing
on the expansion of prevention research to include the prevention of relapse,
disability, and co-occurring conditions, the plan provides a blueprint for NIMH
prevention research in the years to come.
Key Areas of NIMH Research
In total, NIMH supports more than 2,000 research grants and contracts at
universities and other institutions across the nation and overseas. It also
conducts basic research and clinical studies at its own facilities on the
National Institutes of Health campus in Bethesda, MD, and elsewhere. Key areas
of NIMH research include:
basic research on behavior, emotion, and cognition to provide a knowledge base
for a better understanding of mental illnesses;
basic sciences, including cellular and molecular biology, developmental
neurobiology, neurochemistry, neurogenetics, and neuropharmacology, to provide
essential information about the anatomical and chemical basis of brain function
and brain disorders;
neuroscience and behavioral aspects of acquired immune deficiency syndrome
(AIDS) and behavioral strategies to reduce the spread of human immunodeficiency
virus (HIV);
clinical trials to test interventions to treat, prevent, and reduce the
frequency of mental disorders and their disabling consequences;
mental health services research, including mental health economics and improved
methods of services delivery;
co-occurrence among mental disorders and with substance abuse and other medical
conditions, such as depression and heart disease;
the prevalence of mental disorders;
risk factors for mental disorders and protective factors against them;
suicide, suicidal behavior, risk and protective factors, and preventive
interventions;
differences in mental health and mental illness among special populations;
children and adolescents who suffer from or who are at risk for serious mental
disorders and learning disabilities;
aging and mental health, including the impact of caregiving;
responses to terrorist acts and major traumatic events; and
psychotherapies and pharmacotherapies for specific disorders.
For More Information
Please visit the following link for more information about mental health
services.
References
1National Advisory Mental Health Council. Bridging Science and Service: A Report
by the National Advisory Mental Health Council's Clinical Treatment and Services
Research Workgroup. NIH Publication No. 99-4353, 1999.
2NIMH Division of Services and Intervention Research. http://www.nimh.nih.gov/dsir/index.cfm
3Chemtob C. Creating a Collaborative Field Research Organization. NIMH Grant
Number: R24MH063910.
4Trestman R. Mental Health Research Infrastructure in Corrections. NIMH Grant
Number: R24MH067030.
5Samuels J. The Impact of Family CTI Homeless Children. NIMH Grant Number:
R01MH67148.
6Chaffin M. Effectiveness Trial Project SafeCare for Child Neglect. NIMH Grant
Number: RO1MH065667.
7From Intervention Development to Services Research: Exploratory Research
Grants. http://grants1. nih.gov/grants/guide/pa-files/PAR-03-078.html
8State Implementation of Evidence-Based Practices-Bridging Science and Service.
http://grants1.nih.gov/grants/guide/rfa-files/RFA-MH-03-007.html
9Herman D. CTI in the Transition from the Hospital to the Community. NIMH Grant
Number: R01MH059716.
10Wang P. Outreach and Treatment for Depression in the Labor Force. NIMH Grant
Number: R01MH061941.
11Lewis-Fernandez R. Improving Hispanic Retention in Antidepressant Therapy.
NIMH Grant Number: R21MH066388.
12Manson S. American Indian and Alaska Native Mental Health Research. NIMH Grant
Number: P01MH042473-17.
13Morrissey J. Structure, Use & Expenditures for Autism Services. NIMH Grant
Number: R21MH066143.
14Wolff N. Mental Health Services/Criminal Justice Research Center. NIMH Grant
Number: IP20MHD66170-01.
15Steadman H. Cross-Training Curriculum for Professionals Working with Adult
Offenders Presenting with Co-Occurring Disorders. SBIR contract N43MH22055.
16Evidence in Mental Health Services Research: What Types, How Much, and Then
What? Workshop overview and agenda, April 1-2, 2002. http://www.nimh.nih.gov/events/mhsrconf2002.cfm.
17Ibid.
18Frist W. Federal Funding for Biomedical Research: Commitment and Benefits.
Journal of the American Medical Association. 2002; 287:1722-24.
NIH Publication No. 03-5409
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