APPENDIXES



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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH APPENDIXES

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH This page in the original is blank.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH A Summary Committee on Prevention of Mental Disorders 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. Hardly a family in America has been untouched by mental illness. According to estimates from the National Institute of Mental Health, 20 percent of adults in our country suffer from an active mental disorder in a given year, and 32 percent can be expected to have such an illness sometime during their life (Robins and Regier, 1991). The type and nature of mental disorders vary with age. At least 12 percent of the nation's 63 million children and adolescents suffer from one or more mental disorders—including autism, attention deficit hyperactivity disorder, severe conduct disorder, depression, and alcohol and psychoactive substance abuse and dependence (DHHS, 1991; IOM, 1989; OTA, 1986). The American Academy of Child and Adolescent This summary of the report by the Institute of Medicine's Committee on Prevention of Mental Disorders was prepared for members of Congress as a stand-alone document.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Psychiatry (1990) reported that growing numbers of children and adolescents are at exceptionally high risk for developing a mental disorder: for example, 1.5 million children are reported abused or neglected each year. Toward the other end of the life span are the 4 million older Americans who, according to a National Institute on Aging estimate, are likely to be suffering from Alzheimer's disease (Evans, Scherr, Cook, Albert, Funkenstein, Smith et al., 1990) and the 15 to 25 percent of the elderly in nursing homes who are clinically depressed (NIH Consensus Panel on Depression in Late Life, 1992). In addition to the cost in human suffering and lost opportunity, mental illness of this magnitude places an extraordinary burden on the financial and social resources of this country. According to one estimate, the economic costs for 1990 were $98 billion for alcohol abuse, $66 billion for drug abuse, and $147 billion for other mental illness (D. Rice, personal communication, April 1993). Mental and physical health are closely linked, and beyond the costs just described, the contribution of mental health to physical well-being has to be considered. Despite these enormous expenditures, it is estimated that only 10 to 30 percent of those in need receive appropriate treatment (DHHS, 1991; IOM, 1989; NMHA, 1986). Problems on this scale require attacks on many fronts. Major advances in the prevention of health-related problems in several areas of physical health have led the way to an increased awareness of the promise of prevention in enhancing mental health (DHHS, 1991). Childhood immunization programs have prevented numerous physical diseases and large-scale prevention programs have demonstrated notable success in reducing the risk of onset of cardiovascular disease (Flora, Maccoby, and Farquhar, 1989). Could advances of the same magnitude occur in mental health? Could similar successes be achieved in the prevention of disorders such as depression and schizophrenia? Over the years, there have been many efforts to address mental health problems from a prevention perspective (see Table 1). At the same time, Americans have begun to recognize that their physical health and mental health are intertwined. Many people are striving to improve their physical and mental well-being, not just to avoid illness but to achieve what they consider greater personal rewards, including a more active life and a generally more positive disposition (Breslow, 1990). In the report summarized herein, the Institute of Medicine's Committee on Prevention of Mental Disorders examines what is currently known about the prevention of mental disorders and promotion of mental health and outlines the prospects for advances in that knowledge and its application over the next decade.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH TABLE 1 Time Line of Events Related to Prevention of Mental Disorders 1909 The Mental Health Association was founded; subsequently it became the National Association for Mental Health and then the National Mental Health Association (NMHA). Since its inception, it has advocated for prevention of mental illness and promotion of mental health. 1910 Public meeting on “Prevention of Insanity” organized by the New York Committee on Mental Hygiene. Topics included alcoholism, syphilis, drug addiction, head injuries, infectious diseases such as meningitis, and influences of fatigue and stress. 1915 The Proceedings of the National Conference of Charities and Correction contained papers on prevention of mental illness and mental retardation. The ideas included sterilization, reduced immigration, and more institutions to lower the numbers of “feeble-minded” in the community. 1920s The child guidance movement and the mental hygiene movement (fostered by the National Committee for Mental Hygiene that was organized by Clifford Beers) were begun. Both movements were committed to prevention as well as treatment of mental illness and highly valued the role of local communities in solving problems, including prevention of juvenile delinquency. 1930 The White House Conference on Child Health and Protection issued a report with an expanded focus that included social and environmental factors that affect the physical and mental health of children. 1930s The national commitment to prevention decreased, and the treatment-oriented approach began to dominate. Insurance plans created at this time reinforced the illness/treatment approach. 1946 Passage of the National Mental Health Act (P.L. 487) authorized the creation of the National Institute of Mental Health (NIMH). 1948 The World Federation for Mental Health, an independent organization with close ties to the United Nations, was created and included prevention within its purview. 1948 The Mental Health Study Center, a small NIMH community laboratory, was established in Prince Georges County, Maryland, to apply public health principles to the practice of mental health at the community level. For the next 34 years, research was done and treatment and prevention services were provided. 1954 The first organized training program in mental health consultation, which included a prevention component, began at the Harvard School of Public Health, Laboratory of Community Psychiatry. 1955 The Mental Health Study Act directed the Joint Commission on Mental Illness and Health to analyze and evaluate the needs and resources of the mentally ill and make recommendations for a national mental health program. 1961 The Joint Commission on Mental Illness and Health released Action for Mental Health to the Senate and House of Representatives. 1963 President John F. Kennedy, in a message to Congress, championed prevention as an approach to the problem of mental illness.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1963 The Community Mental Health Centers Act listed mental health consultation and education, which included prevention, as one of the five essential services necessary for such centers to qualify for federal funds. This was the first time in any federal health statute that a preventive service was declared mandatory. 1969 The Joint Commission on Mental Health of Children produced a report saying that millions of children were in need of services, and millions were at risk. 1973 NMHA formed a Prevention Task Force. 1975 The first Vermont Conference on the Primary Prevention of Psychopathology was sponsored by the World Federation for Mental Health, NIMH, and the John D. and Catherine T. MacArthur Foundation. 1976 The Conference on Primary Prevention sponsored by NIMH resulted in Primary Prevention: An Idea Whose Time Has Come. 1978 The President's Commission on Mental Health reported that (1) efforts to prevent mental illness and promote mental health were unstructured, unfocused, and uncoordinated and (2) preventive efforts received insufficient attention at the federal, state, and local levels. The commission recommended establishing a Center for Prevention in NIMH. 1978 The position of Coordinator for Disease Prevention and Health Promotion was established at the National Institutes of Health (NIH). 1979 The first annual Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Conference on Prevention was held. 1980 The NIH Prevention Coordinating Committee was formed, with the NIH Coordinator for Disease Prevention and Health Promotion as the designated prevention coordinator. 1980 The Public Health Service Act (in response to the presidential endorsement of the 1978 President's Commission on Mental Health) was amended to give special attention to efforts to prevent mental disability. Among other requirements, this act and a 1983 amendment (1) established the Office of the Deputy Director for Prevention and Special Projects in NIMH, and (2) designated an Associate Administrator for Prevention within ADAMHA to promote and coordinate prevention programs, including those run by NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Associate Administrator was made responsible for an annual report to Congress describing the prevention activities undertaken by ADAMHA and its agencies. 1980 NIDA established its Prevention Research Branch. 1981 The Select Panel for Promotion of Child Health (established by Public Law 95–626) presented its findings to the U.S. Congress and the Secretary of Health and Human Services. The panel reported a need for better coordination of mental health and health services due to the frequent concomitance of health and mental health problems in children. 1981 The Omnibus Budget Reconciliation Act folded the community mental health centers into alcohol, drug abuse, and mental health block grants to the states and introduced large cuts in all human service appropriations.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1982 The Center for Prevention Research (CPR) was established at NIMH. This was a step toward consolidation of preventive intervention research throughout NIMH into one unit. 1983 NIMH Center for Prevention Research established its first Prevention Intervention Research Center (PIRC). 1983 ADAMHA Associate Administrator for Prevention was appointed, as mandated by an amendment to the Public Health Service Act, to promote and coordinate the research programs of its component agendes—NIAAA, NIDA, and NIMH. 1984 NMHA established the Commission on the Prevention of Mental-Emotional Disabilities. 1985 NIMH appointed its first Deputy Director for Prevention, mandated by the 1980 Public Health Service Act. 1985 The Office of Substance Abuse Prevention (OSAP) was established. 1985 NIDA published the first of several monographs dealing with preventing drug abuse. 1985 The Center for Prevention Research reorganized into the Prevention Research Branch within the newly created Division of Clinical Research in NIMH. 1986 A prevention initiative was undertaken by the American Academy of Child and Adolescent Psychiatry, and a Project Prevention Steering Committee was formed. The initiative resulted in a series of prevention monographs published by OSAP. 1986 NIAAA established the Prevention Research Branch within the Clinical and Prevention Research Division, created at the same time. 1986 The position of Assistant Director for Disease Prevention at the Office of Director level was established within NIH. 1986 The Office of Technology Assessment (OTA) issued a report entitled Children's Mental Health: Problems and Services. The report concluded that there was a substantial theoretical and research base to show that mental health interventions were effective for children. 1986 NMHA released a report by the Commission on the Prevention of Mental-Emotional Disabilities, The Prevention of Mental-Emotional Disabilities. 1987 NIMH published Preventing Mental Disorders: A Research Perspective. 1987 The National Prevention Coalition was established within NMHA. 1989 The U.S. General Accounting Office issued a report to Senator Inouye, Mental Health: Prevention of Mental Disorders and Research on Stress-Related Disorders, a critique of the implementation of prior recommendations in the prevention field. 1989 The Institute of Medicine (IOM) issued Research on Children and Adolescents with Mental, Behavioral, and Developmental Disorders: Mobilizing a National Initiative. Prevention was not emphasized. 1990 Because of a congressional mandate, NIMH entered into an agreement with IOM so that IOM could prepare an integrated report of current prevention research, with policy-oriented and detailed long-term recommendations for a prevention research agenda.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 1990 The American Psychiatric Association published a report prepared by the Task Force on Prevention Research of the Council on Research with a review of research on the prevention of psychiatric disorders. 1990 The American Academy of Child and Adolescent Psychiatry published Prevention in Child and Adolescent Psychiatry: The Reduction of Risk for Mental Disorders. 1990 A National Plan for Research on Child and Adolescent Mental Disorders (National Advisory Mental Health Council) emphasized scientific research concerning biomedical risk factors and capacity building for scientific researchers. 1990 NIMH held its first National Conference on Prevention Research, and a NIMH Steering Committee on Prevention was established to write a report on the current status of prevention research within NIMH. 1992 The ADAMHA Reorganization Act abolished ADAMHA, organized the three research institutes (NIAAA, NIDA, and NIMH) under NIH, and provided for an Associate Director for Prevention in each research institute. The service components from ADAMHA were reorganized into the Substance Abuse and Mental Health Services Administration (SAMHSA) as the Center for Substance Abuse Treatment, the Center for Substance Abuse Prevention, and the Center for Mental Health Services. 1992 The IOM Committee on Prevention of Mental Disorders was formed in accordance with the NIMH agreement. 1993 NIMH Steering Committee on Prevention released The Prevention of Mental Disorders: A National Research Agenda at the third NIMH National Conference on Prevention Research. OPPORTUNITIES AND OBSTACLES The committee undertook its broad review of the status of prevention research at the request of Congress and the National Institute of Mental Health and co-funding agencies.* It found encouraging opportunities and strengths and a number of obstacles. To date, progress in prevention has been limited because efforts have been sporadic and often have lacked focus. Problems have included difficulties in identifying, defining, and classifying mental disorders; a perception that the knowledge base—including an understanding of etiologies and risk mechanisms—is too small to support preventive interventions; and confusion regarding the terms prevention and prevention research. But the knowledge base has undergone remarkable expansion within the past decade. *The co-funding agencies were the National Institute of Mental Health (NIMH), the Administration on Children, Youth, and Families, the Maternal and Child Health Bureau, the Center for Substance Abuse Prevention, the Office of the Assistant Secretary for Planning and Evaluation, the Office of the Assistant Secretary for Health, and the Office of Disease Prevention and Health Promotion.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Fundamental advances in our understanding of the biological substrates and genetics underlying numerous mental disorders and the role of environmental factors in the onset of specific disorders have been made. There are a number of promising new preventive interventions. The committee believes that it is time to take a fresh look at prevention to see if it can be made to function as a full partner with new treatment approaches in addressing our nation's mental health care crisis. NEW DIRECTIONS IN DEFINITIONS An essential first step in a renewed prevention effort is to arrive at commonly agreed upon definitions for key terms. Two systems for classifying types of interventions for mental disorders are currently in use. But both the public health classification system of primary, secondary, and tertiary prevention (Commission on Chronic Illness, 1957) and Gordon's (1987, 1983) system of universal, selective, and indicated prevention are focused on prevention of disorders traditionally identified as medical disorders, and the application of these terms to a mental health framework is problematic. “To prevent” literally means “to keep something from happening.” But within the field of mental health, there are different notions about what that something is—first incidence, relapse, disability associated with a disorder, or the risk condition itself. Therefore, for application to mental disorders, the term prevention needs to be more carefully circumscribed than it is in either of these systems. In Chapter 2 of this report, the committee presents a classification system that is tailored for mental disorders and in which the term prevention is reserved for those interventions that occur before the initial onset of disorder. Treatment (for individuals who meet or are close to meeting diagnostic criteria) and maintenance (for diagnosed individuals whose illness continues) complete the committee's vision of the spectrum of interventions for mental disorders (see Figure 1). The change in terminology that is used throughout this report, although perhaps not particularly useful to clinicians, who may find themselves providing elements of prevention, treatment, and maintenance to the same patient, is critical to a review of prevention research. Without a system for classifying specific interventions, there is no way to obtain accurate information on the type or extent of current activities, either public or private, and no way to ensure that prevention researchers, practitioners, and policymakers are speaking the same language. To further classify interventions within prevention, the committee has adapted the terms used by Gordon. Universal preventive interventions for *The co-funding agencies were the National Institute of Mental Health (NIMH), the Administration on Children, Youth, and Families, the Maternal and Child Health Bureau, the Center for Substance Abuse Prevention, the Office of the Assistant Secretary for Planning and Evaluation, the Office of the Assistant Secretary for Health, and the Office of Disease Prevention and Health Promotion.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH FIGURE 1 The mental health intervention spectrum for mental disorders. mental disorders are targeted to the general public or a whole population group that has not been identified on the basis of individual risk. Such interventions have advantages when their cost per individual is low, the intervention is effective and acceptable to the population, and there is a low risk from the intervention. However, it is crucial to be realistic about costs. An intervention provided to every prospective marital couple, although low in cost per couple, would be very expensive overall because of the size of the target group. Selective preventive interventions are targeted to individuals or a subgroup of the population whose risk of developing mental disorders is significantly higher than average. The risk may be imminent, or it may be a lifetime risk. Risk groups may be identified on the basis of biological, psychological, or social risk factors that are known to be associated with the onset of a mental disorder. Selective interventions are most appropriate if the interventions do not exceed a moderate level of cost and if negative effects are minimal or nonexistent. Indicated preventive interventions are targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental disorder, or biological markers indicating predisposition for the mental disorder, but who do not meet DSM-III-R diagnostic levels at the current time. The term indicated is used differently here from how Gordon used it. Whereas he meant it to apply only to asymptomatic individuals, within this mental health classification system it can be applied to asymptomatic individuals with markers as

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH well as to symptomatic individuals whose symptoms are still early and are not sufficiently severe to merit a diagnosis. Indicated interventions may be reasonable even if intervention costs are high and even if the intervention entails some risk. The committee does not include mental health promotion within the spectrum of interventions focused on mental disorders because health promotion is not driven by an emphasis on illness, but rather by a focus on the enhancement of well-being. It is provided to individuals, groups, or large populations to enhance competence and self-esteem rather than to intervene to prevent psychological or social problems or mental disorders. Nevertheless, promotion is an important approach to mental health, and therefore Chapter 9 presents a capsulized look at its status. THE RISK REDUCTION MODEL The long-term goal of all three types of preventive intervention—universal, selective, and indicated—is the reduction of the occurrence of new cases of mental disorder. Usually, this is attempted through a risk reduction model, wherein the short-term goal is the reduction of the risk factors and the enhancement of the protective factors that have been shown to be associated with the onset of the disorder. Risk factors are those characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected from the general population, will develop a disorder (Werner and Smith, 1992; Garmezy, 1983). Many at-risk individuals also have variables in their background or life that serve as protective factors. A well-documented description of the interplay between risk and protective factors is a critical scientific first step in establishing successful preventive intervention programs. Such a description is now available for some disorders, and research is under way to identify such factors for a number of others. The next step is to identify causal risk factors that may be malleable, that is, that can be altered through interventions. Then the effects of these interventions are tested in systematic, empirical, and rigorous ways, most often in preventive intervention trials. If risk factors can be decreased or in some way altered, and/or if protective factors can be enhanced, the likelihood that at-risk individuals would eventually develop the mental disorder would decrease. As described in Chapter 3, this risk reduction model is widely used for prevention of physical illness. To prevent physical disorders due to complex multiple causes, the strategy is to determine risk factors and then to target interventions to such risk factors or to people with these risk factors. Progress has been notable in many areas, including the

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 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 Services 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. 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 modifi-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH able 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 possible, the standards developed in this report, including hypothesis-driven randomized controlled trials and assessment of multiple outcome measures over time, should be instituted.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 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 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 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 inter-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH vention 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 where 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 intervention 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 (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

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 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 quite 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-occuring 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. Co-existing 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. 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,

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 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. Funding Preventive intervention research (excluding the specialized prevention research centers) should be budgeted at $20 million above the FY

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 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. The need for effective preventive programs in clear. It is equally clear that to obtain such programs we need a national commitment to rigorous research and increased support for the infrastructure to make that research possible.

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