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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for the appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is the president of the Institute of Medicine.
The work on which this project is based was performed pursuant to Contract No. NIMH-OD-91–0014 with the National Institute of Mental Health.
Library of Congress Cataloging-in-Publication Data
Reducing risks for mental disorders: frontiers for preventive intervention research/Committee on Prevention of Mental Disorders, Division of Biobehavorial Sciences and Mental Disorders, Institute of Medicine; Patricia J. Mrazek and Robert J. Haggerty, editors.
p. cm.
Prepared at the request of the U.S. Congress.
Includes bibliographical references and index.
ISBN: 0–309–04939–3
1. Mental illness—Prevention—Research—Government policy—United States. 2. Mental health promotion—Research—Government policy—United States. 3. Mental illness—United States—Prevention. 4. Mental health promotion—United States. I. Mrazek, Patricia Beezley. II. Haggerty, Robert J. III. Institute of Medicine (U.S.). Committee on Prevention of Mental Disorders. IV. United States. Congress.
[DNLM: 1. Mental Disorders—prevention & control—United States. 2. Risk Factors. 3. Preventive Psychiatry. WM 100 R321 1994]
RA790.6.R44 1994
362.2′0425′0973—dc20
DNLM/DLC
for Library of Congress
92-47911
CIP
Copyright 1994 by the National Academy of Sciences. All rights reserved.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
Printed in the United States of America.
Committee on Prevention of Mental Disorders
ROBERT J. HAGGERTY * (Chair), Professor of Pediatrics Emeritus,
University of Rochester School of Medicine and Dentistry, Rochester, New York
BEATRIX A. HAMBURG * (Vice-Chair), President,
William T. Grant Foundation, New York, New York
WILLIAM R. BEARDSLEE, Associate Professor of Psychiatry,
Harvard Medical School, Boston, Massachusetts
ROLAND D. CIARANELLO, Professor of Psychiatry and Behavioral Sciences,
Stanford University Medical Center, Stanford, California
JOSEPH T. COYLE, * Eben S. Draper Professor of Psychiatry and of Neuroscience, Chair of the Consolidated Department of Psychiatry,
Harvard Medical School, Belmont, Massachusetts
WILLIAM W. EATON, Professor,
Department of Mental Hygiene, School of Hygiene and Public Health, The Johns Hopkins University Hospital, Baltimore, Maryland
J. DAVID HAWKINS, Professor and Director,
Social Development Research Group, School of Social Work, University of Washington, Seattle, Washington
FRITZ A. HENN, Professor and Chairman,
Department of Psychiatry and Behavioral Medicine, State University of New York at Stony Brook, Stony Brook, New York
ROBERT P. LIBERMAN, Professor of Psychiatry, UCLA School of Medicine; Director,
Clinical Research Center for Schizophrenia, Los Angeles, California
BEVERLY B. LONG, Chair,
International Committee on Primary Prevention, and
President-Elect,
World Federation for Mental Health, Atlanta, Georgia
SPERO M. MANSON, Professor and Director,
National Center for American Indian and Alaska Native Mental Health Research, University of Colorado Health Sciences Center, Denver, Colorado
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
RICARDO F. MUÑOZ, Professor of Psychology,
University of California, San Francisco, San Francisco General Hospital, San Francisco, California
HERBERT W. NICKENS, Vice-President of
Minority Health, Education, and Prevention, Association of American Medical Colleges, Washington, D.C.
RICHARD H. PRICE, Professor of Psychology and Research Scientist,
Institute for Social Research, University of Michigan, Ann Arbor, Michigan
NAOMI RAE GRANT, Professor and Head, Division of Child Psychiatry, Department of Psychiatry,
The University of Western Ontario, London, Ontario, Canada
*IOM Member |
†NAS Member |
Institute of Medicine Staff
ROBERT M. COOK-DEEGAN, Director,
Division of Biobehavioral Sciences and Mental Disorders
CONSTANCE M. PECHURA, Associate Director,
Division of Biobehavioral Sciences and Mental Disorders
PATRICIA J. MRAZEK, Study Director
CAROLYN E. PETERS, Research Assistant
CAROL M. HOSPENTHAL, Project Assistant
Preface
Mental disorders cause an enormous burden on affected individuals, their families, and society. While impressive advances have been made in the past two decades in defining, diagnosing, and treating many of the major mental illnesses once they become full blown, many of these disorders are characterized by a chronic or relapsing course that has high personal and economic costs to all concerned. Cures are rare. Therefore, the logic of trying to prevent the occurrence of mental disorders is clear. Yet, in sharp contrast to the situation in the physical diseases, efforts to prevent mental disorders have had low priority. Many voices have been raised to correct this gap, including Congress, who charged the Institute of Medicine to prepare an integrated report of current research with policy-oriented and detailed long-term recommendations for a prevention research agenda for mental disorders.
The committee appointed by the IOM to carry out this task provided the diversity, the wide view, and the expert knowledge that this field demands. It included a range of disciplines, including adult and child psychiatry, psychology, pediatrics, epidemiology, sociology, anthropology, and public advocacy (see Appendix B).
The committee's process was a multipronged effort. It involved extensive review of a literature that is large in volume but limited in rigorous evaluation of interventions. Conferences were convened with experts who had conducted large-scale interventions to prevent physical diseases, and with experts in the fields of ethics and cultural diversity; and there were spirited committee meetings, in which the form and
substance of the report were debated with an eye towards forging consensus in the final report. The committee examined some agency budget figures, but it was difficult to get firm data. In addition, several background papers were commissioned (see Appendix D). Committee members themselves contributed to many of the technical sections of the report. The conclusions and recommendations the committee makes in this report are based on its best judgment of the information and data that were available for review.
The committee concludes that the federal government should take several actions. For some mental disorders there have now been sufficient advances in knowledge to warrant the prompt mounting of intensive interventions designed to prevent mental disorders, so long as these programs are rigorously evaluated. For other conditions there is still the need for development of an adequate knowledge base before sound theoretically-based interventions are warranted. For the field in general there needs to be support for training of a cadre of investigators and for coordination of the currently fragmented efforts in prevention of mental disorders across the many departments of government and the private sector.
The committee recognized early that disparate definitions of the field of prevention were causing confusion in preventing mental disorders. The committee, therefore, developed a set of definitions to provide common terminology and to help achieve a common understanding of what is being done in the field. To date, the definitions have been so broad and flexible that almost everything has been labeled prevention at one time or another. The committee's more restrictive definition excludes interventions aimed at reducing recurrences among patients with diagnosed illnesses. Instead, we have labeled such programs as a part of good treatment. While there are honorable differences of opinion as to whether this should be called prevention, the committee recommends that for purposes of monitoring federal research and demonstration efforts, prevention research be limited to processes that occur before there is a diagnosable mental illness. When the new definition of prevention is used, we will be able to understand better what is being done in prevention per se. Our estimate is that the field of research on true prevention of mental illness, by our definition, is very small.
The committee recognizes the considerable barriers to progress in the prevention field. Currently there is little evidence from research that any specific mental disorder can be prevented. There is, however, considerable evidence that certain risk factors (some of which are causal of and some only markers of mental disorders) have been clearly identified. Using the model found effective in the prevention of physical disorders,
it seems quite appropriate to initiate interventions designed to reduce these identified risk factors (and also to enhance known protective factors) with rigorous evaluations of outcomes. One advantage of targeting interventions on risk factors is that certain clusters of them are common to several disorders, and the potential for reducing more than one disorder by comprehensive intervention is appealing and is likely to be more cost effective.
For other disorders the knowledge base is yet too small and must be further developed before theoretically sound interventions can be tested. Promising areas of research are delineated. For many mental disorders, there is now convincing evidence for a genetic predisposition, but in practically all disorders there is also evidence that the genetic factors do not act alone, and that environmental factors can precipitate, or delay, onset. Therefore, research on understanding the causes of mental disorders must integrate biologic and behavioral sciences. In addition, there is considerable evidence that many mental disorders are brought on by physical diseases and that behavioral factors initiate or delay onset of physical disease. The committee urges more research in the interactions between physical and mental disorders.
The quality of the Institute of Medicine staff was crucial to the development of this report. Dr. Patricia J. Mrazek, the study director, brought a background in both service experience and research expertise, together with her organizational skills and uncompromising attention to scientific evidence, to all aspects of the committee's work. She did most of the writing of the report, ably assisted by Carolyn Peters and Carol Hospenthal. We are very grateful for their skills and dedication.
We believe that the U.S. Congress was wise to initiate this timely review of the field of prevention of mental disorders. The field is so important that the nation must invest the relatively small amounts recommended in this report to capitalize on the advances already made and to develop the knowledge base necessary for future advances. The one-third of our nation who today face the threat of mental disorder during their lifetime will be immediate beneficiaries when effective prevention programs are implemented, and the nation as a whole will ultimately benefit from the lifting of the burden mental disorders placed upon it. The time is right to move ahead with a national agenda to prevent mental disorders.
ROBERT J. HAGGERTY, M.D., Chair
BEATRIX A. HAMBURG, M.D., Vice-Chair
Acknowledgments
The Committee on Prevention of Mental Disorders expresses its appreciation to the agencies within the Department of Health and Human Services that co-funded this 24-month study: 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.
Many people outside of the committee contributed to this study in various ways. The committee gratefully acknowledges the enthusiastic support of Dr. Juan Ramos, Deputy Director of Prevention at NIMH and project officer for this study; the excellent assistance of Roseanne Price, who collaborated in the editing and writing of the report; and all of those who contributed by writing commissioned background papers, providing technical reviews of drafts of chapters, and making presentations to the committee. Many others contributed by providing preventive intervention research or service program materials, technical and funding information, and moral support. To all of you, the committee offers its sincere gratitude. The names and affiliations of contributors are listed in Appendix B; additionally, authors of commissioned papers are acknowledged in the relevant chapters. To anyone who was overlooked, please accept the committee's apologies and appreciation.
Abstract
Hardly a family in America has been untouched by mental illness. As many as one third of American adults will suffer a diagnosable mental disorder sometime in their life, and 20 percent have a mental disorder at any given time. 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.
The Senate Appropriations Committee of the U.S. Congress believed that a strategic approach to the prevention of mental disorders was warranted. The Congress mandated the National Institute of Mental Health to enter into an agreement with the Institute of Medicine (IOM) to prepare an integrated report of current research with policy-oriented and detailed long-term recommendations for a prevention research agenda.
The specific tasks of the IOM committee, as negotiated with NIMH and the co-funding agencies, were as follows:
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Review the status of current research on the prevention of mental illness and problem behaviors and on the promotion of mental health throughout the life span. This should include an understanding of available research knowledge, research priorities, and research opportunities in the prevention research area.
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Review the existing federal presence in the prevention of mental disorders and the promotion of mental health, spanning the continuum from research to policy and services.
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Provide recommendations on federal policies and programs of
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research support leading to a prevention research agenda as well as on opportunities for maximization of involvement and improvement of coordination among federal agencies.
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Render a “capacity-building” plan for the development of personnel and resources necessary to ensure a cadre of prevention researchers.
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Provide an estimate of resources (funding, manpower, training opportunities) necessary to make effective scientific progress in prevention research.
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Prepare a final report that will encourage universities, colleges, hospitals, and federal agencies to foster prevention research.
The committee concludes that a critical mass of knowledge relevant to the prevention of mental disorders has accumulated and that opportunities now exist to effectively use this knowledge to launch a research agenda. 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 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.
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Expanding the knowledge base for preventive interventions.
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Conducting well-evaluated preventive interventions.
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, depending on the targeted population group. The term prevention research, as used in this report, refers only to preventive intervention research and is distinct from research that builds a broad scientific base for preventive interventions. This latter research is prevention-related, but it is not prevention research per se.
BUILDING THE INFRASTRUCTURE
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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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.
Therefore 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.
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The committee also strongly recommends that Congress encourage the establishment of offices for prevention of mental disorders at the state level.
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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.
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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.
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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.
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Dissemination activities should receive much higher priority than they have in the past.
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Congress and federal agencies should take steps immediately to develop and support the training of additional researchers who can
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develop new preventive intervention research trials as well as evaluate the effectiveness of current service projects.
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Research training should be focused on two groups—mid-career scientists and postdoctoral students.
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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.
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Support for faculty within institutional training programs should be increased.
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A major effort should be made to encourage the prevention research training of minorities.
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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.
EXPANDING THE KNOWLEDGE BASE
The committee believes 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 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. Therefore,
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Research to expand the knowledge base for preventive interventions should be continued.
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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 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 alone.
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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.
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A population laboratory should be established with the capacity
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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. Therefore,
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Increased methodological rigor in all research trials, demonstration projects, and service program evaluations should be required.
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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.
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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.
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Research on selective and indicated interventions targeting high-risk groups and individuals should be given high priority.
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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.
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Increased attention should be given to preventive intervention research that addresses the overlap between physical and mental illness.
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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 preventive intervention research centers.
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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.
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Research on preventive interventions aimed at major depressive disorder should be increased immediately and substantially.
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Research on preventive interventions aimed at alcohol abuse should be increased immediately.
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Support for pilot and confirmatory preventive intervention trials should be increased for conduct disorder.
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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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Over the next decade, as new specialized prevention research centers are initiated across the federal government, priority should be given to those that are sponsored through interagency agreement.
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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.
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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.
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The preventive intervention research cycle as described in this report should be used as a conceptual model for designing, conducting, and analyzing research programs.
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Increased attention to cultural diversity, ethical considerations, and benefit-cost and cost-effectiveness analyses should be an essential component of preventive intervention research.
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Community involvement should be increased to help identify
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disorders and problems that merit research and to support preventive intervention research programs.
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. The committee recommends increased support for a research agenda, beginning with an increase of $50.5 million in fiscal year 1995. But even with the support of the federal government, the effort will not be easy. Overall, what is required is a national commitment to rigorous research and cooperation among federal, state, and local agencies, as well as universities, foundations, researchers, and communities.
List of Boxes, Figures, and Tables
BOXES
4.1 |
Illustrations from the Behavioral and Social Sciences, |
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6.1 |
Children of Parents with Schizophrenia: Family History as a Risk Factor, |
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6.2 |
Children of Parents with Alcohol Abuse and Dependence: Multiple Psychosocial Risk Factors for Their Development, |
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6.3 |
Children of Parents with Mood Disorders: Opportunities for Prevention, |
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6.4 |
Low Birthweight as a General Risk Factor, |
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6.5 |
Quality of Interaction with Parents as a General Protective Factor, |
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6.6 |
Child Maltreatment, |
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11.1 |
Case Study: Replication of the Prenatal/Early Infancy Project, |
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12.1 |
Maternal and Child Health Bureau, |
FIGURES
1.1 |
The Preventive Intervention Research Cycle, |
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2.1 |
The Mental Health Intervention Spectrum for Mental Disorders, |
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5.1 |
Annual Incidence of DIS/DSM-III Alcohol Abuse/Dependence, |
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5.2 |
Age of Onset of DIS/DSM-III Alcohol Abuse and Dependence, |
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5.3 |
Age of Onset of DIS/DSM-III Antisocial Personality Disorder, |
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5.4 |
Age of Onset of DIS/DSM-III Major Depressive Disorder, |
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5.5 |
Age of Onset of DIS/DSM-III Schizophrenia, |
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5.6 |
Age of Onset of DIS/DSM-III Cognitive Impairment, |
7.1 |
A Framework for Examining Preventive Interventions, |
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7.2 |
Developmental Tasks and Social Fields for Preventive Interventions Over the Life Course, |
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10.1 |
The Preventive Intervention Research Cycle, |
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10.2 |
Measurement Points Along the Time Line for the Intervention Trial and Follow-up Period, |
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10.3 |
Survival Function Estimates, |
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11.1 |
The Process by Which Practitioners and Policymakers Access Knowledge Based on Prevention Research, |
1.1 |
Time Line of Events Related to Prevention of Mental Disorders, |
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2.1 |
U.S. Public Health Service Definition of Prevention Research, |
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5.1 |
DSM-III-R Diagnostic Criteria for Conduct Disorder, |
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5.2 |
DSM-III-R Diagnostic Criteria for Antisocial Personality Disorder, |
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5.3 |
DSM-III-R Diagnostic Criteria for Major Depressive Episode and for Major Depression, |
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5.4 |
DSM-III-R Diagnostic Criteria for Dysthymia, |
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5.5 |
DSM-III-R Diagnostic Criteria for Psychoactive Substance Abuse and Psychoactive Substance Dependence, |
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5.6 |
DSM-III-R Diagnostic Criteria for Schizophrenia, |
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5.7 |
DSM-III-R Diagnostic Criteria for Primary Degenerative Dementia of the Alzheimer Type and Dementia, |
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5.8 |
Prevalence Data on DSM-III Major Depressive Disorder in the General Population by Age: A Review of Selected Studies of Children and Adolescents, |
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7.1 |
Illustrative Preventive Intervention Programs Using Randomized Controlled Trial Design, |
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11.1 |
Journals Cited Most Often in the NIMH Prevention Bibliography, 1983 to 1991, |
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11.2 |
Publications from the NIMH Preventive Intervention Research Centers (as of August 1993), |
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11.3 |
Clearinghouses That Provide Information Related to the Prevention of Mental Disorders, |
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12.1 |
Prevention Research Projects Funded by Agencies of NIH and the Former ADAMHA According to CRISP Definitions and Files, |
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12.2 |
Prevention Activities Funded by NIMH, NIDA, and NIAAA, |
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12.3 |
Support Received for the NIMH PRB Preventive Intervention Research Centers (PIRCs), |
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12.4 |
Support Received for the NIDA Epidemiology and Prevention Research Centers, |
12.5 |
Breakdown of NIMH Prevention Research Branch Budget for FY 1992, |
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12.6 |
Federal Agencies Involved in Preventive Intervention Research and/or Preventive Intervention Services Related to Mental Disorders, |
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12.7 |
Department of Health and Human Services Agencies Reporting Prevention Activities in Priority Areas, 1991, |
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12.8 |
NIMH Grant Mechanisms That Can Be Used for Research Training or Related Activities, |
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13.1 |
Recommendations for Federal Government Support Above 1993 Level of Support, |