TRANSLATING 

BEHAVIORAL 

SCIENCE INTO 

ACTION:

REPORT OF THE

NATIONAL ADVISORY MENTAL 

HEALTH COUNCIL

BEHAVIORAL SCIENCE 

WORKGROUP
ii

EXECUTIVE SUMMARY

A. INTRODUCTION 

The current social and economic burden of mental illness in America is enormous. Its 

toll includes more than $148 billion a year in direct and indirect costs, and an 

incalculable amount of suffering for a sizeable proportion of our population. Mental 

disorders also account for more than 10 percent of the global burden of disease. Four 

mental disorders (unipolar major depression, bipolar disorder, schizophrenia, and 

obsessive-compulsive disorder) rank among the 10 leading causes of disability 

worldwide, with unipolar major depression leading the entire ranking. A public health 

challenge of this magnitude demands the best science we can offer to improve mental 

health and clinical care in the United States and beyond. 

This report focuses on ways to enhance the potential contributions of one specific area 

of science--behavioral science1--a bedrock of the National Institute of Mental Health 

(NIMH) research since the Institute was founded in the late 1940s. It suggests new 

ways to build on the Institute's rich portfolio of basic behavioral science to reach its 

public health goals in the 21st century. 

Behavioral science can offer critical insights into the nature of mental illness and health 

and the processes and interventions that can prevent illness or lead from disorder to 

remission, recovery, and rehabilitation. It is clear, however, that the field, which has 

yielded great practical benefits for education, the military and industry, as well as many 

health areas, has much more to offer in mental health. Many findings that might inform 

interventions have not yet been applied in the clinical and services domain; others 

remain to be explored and developed. 

As suggested by the Workgroup's findings (see Chapter II), addressing major 

communication issues could strengthen the application of behavioral science knowledge 

to clinical care and service delivery:

• Communication and collaboration between basic scientists and clinical and 

services researchers;

 

1 See NIH definition of behavioral and social sciences research, Appendix A. Please note that this 

document uses the terms "behavioral science," “behavioral research," “behavioral science research," and 

“behavioral and social science" interchangeably, as it does the terms "consumer," "client," and “patient." 
iii

• Engagement by the scientific community in research identified as important by 

consumers, family members, providers, and payers;

• Adoption, development, and dissemination of essential research tools and 

methods for translational research, and sharing of research findings among 

laboratory scientists, clinical researchers, and services researchers; and

• Translation of relevant research to other stakeholders.

In this report, the National Advisory Mental Health Council's (NAMHC) Behavioral 

Science Workgroup recommends ways to help NIMH foster translational research2 that 

addresses effectively many of the core problems facing people with mental illness. 

Such research can shed light on risk, prevention, treatment, rehabilitation and the 

organization, delivery, and use of services. A summary of major priority research areas 

and recommendations for NIMH leadership in developing research in these areas 

follows.

B. PRIORITY TRANSLATIONAL BEHAVIORAL SCIENCE RESEARCH AND

 FUNDING AREAS

The Workgroup has chosen to highlight three specific areas of study in which the push 

of research progress converges with the pull of public health need (i.e., the real-world 

needs of consumers, practitioners, payers, and policymakers) to create prime targets for 

intensified study. These priority research areas are critical starting points for progress 

in translational science because they are at the interface of what end-users have 

identified as important and what behavioral science researchers regard as areas of 

opportunity. They offer the prospect of conducting exciting research, advancing 

scientific understanding of behavior--in health and in illness--and improving the mental 

health of our Nation. (For discussion of specific research directions within these priority 

areas, see Chapter III.) 

PRIORITY AREA 1: BASIC BEHAVIORAL PROCESSES IN MENTAL ILLNESS

Understand how basic behavioral processes (e.g., cognition, emotion, motivation, 

development, personality, social interaction) are altered in mental illnesses, how 

these processes relate to neurobiological functioning, and the implications of 

these alterations for etiology, diagnosis, course, prevention, treatment, and 

rehabilitation.

• Develop reliable and valid methods for assessing these basic behavioral 

processes as part of clinical diagnosis. 

• Assess how preventive, treatment, and rehabilitative interventions affect these 

basic behavioral processes.

 

2

 Translational research in the behavioral and social sciences addresses how basic behavioral processes 

inform the diagnosis, prevention, treatment, and delivery of services for mental illness, and, conversely, 

how knowledge of mental illness increases our understanding of basic behavioral processes.
iv

• Evaluate these basic behavioral processes as indicators of risk for the 

development or exacerbation of mental illness.

• Combine basic behavioral research with neuroscientific, pharmacological, and 

genetic research to produce an integrated approach to understanding, 

preventing, and treating mental illness. 

PRIORITY AREA 2: FUNCTIONAL ABILITIES IN MENTAL ILLNESS

Understand how mental illnesses and their treatments affect the abilities of 

individuals to function in diverse settings and roles (e.g., carrying out personal, 

educational, family, and work responsibilities).

• Apply methods from basic behavioral science to the development of tools to 

assess functioning. 

• Use methods from basic behavioral science to understand how specific 

rehabilitation and other intervention techniques improve specific types of 

functioning.

• Develop interventions that focus on improving functioning in addition to reducing 

clinical symptoms.

• Include the assessment of functioning as an outcome in intervention, services, 

and risk-factor research. 

PRIORITY AREA 3: CONTEXTUAL INFLUENCES ON MENTAL ILLNESS 

AND ITS CARE

Understand how social or other environmental contexts influence the etiology 

and prevention of mental illness and the treatment and care of those suffering 

from mental disorders. Context includes interactions among factors at the 

individual, family, sociocultural, and service-system or organizational levels. 

Examples include: 

• Individual: How social and cultural influences at the individual level--such as 

developmental history, styles of expressing emotion, levels of motivation, 

personality, beliefs, values, preferences, needs, and goals--affect risk for mental 

illness and inform the development, design, and targeting of new interventions, 

and how such characteristics affect behavioral responses to prevention and 

treatment.

• Sociocultural: How ethnicity, culture, language, socioeconomic class, family 

and social networks, and neighborhood or community affect risk, diagnosis, 

prevention, and treatment of mental illness.
v

• Organizational: How policies, incentive structures, and cultures at all levels of 

health/mental health organizations and institutions affect the behavior of those 

providing care and of those receiving it, as well as the outcomes of care.

The three priority behavioral research areas are so central to the core mission of NIMH 

that it may seem puzzling that the Workgroup needs to highlight them for special 

encouragement. They pose many interesting research questions that should attract and 

excite a substantial number of behavioral scientists spontaneously. However, such 

research is sparse at best in the current NIMH portfolio, suggesting that these are 

difficult areas to develop. At present too few researchers are attempting to bridge

across basic, clinical, and services research, and not enough are working with 

colleagues in related allied disciplines to move research advances out of the laboratory 

and into clinical care, service delivery, and policymaking. 

NIMH can and must play a catalytic role in initiating and sustaining the best possible 

science in all three priority areas of behavioral translational research. Because 

research topics within these areas are at different stages of development, they will 

require different strategies and timetables for moving forward. But all priority areas will 

benefit from a systematic, phased approach to development that assesses their current 

status and needs, their potential contributions to clinical care and service delivery, and 

the steps required to realize those contributions. To be successful in these efforts, 

NIMH, of course, must embody in its administration of translational research the same 

spirit of multidisciplinary collaboration and coordination that it fosters in the research 

community. 

The Institute stimulates outstanding mental health research through a blend of scientific 

leadership and efficient research administration. As the leading supporter of basic and 

clinical behavioral science, as well as treatment research and services research related 

to mental illnesses, NIMH is strongly positioned to build a successful and enduring 

program of translational behavioral research. However, the Institute needs to develop a 

comprehensive approach to building, sustaining, and applying systematically the 

behavioral knowledge needed to improve critical aspects of mental health care. Doing 

so requires making efficient and effective use of its considerable resources and roles, 

which include, in addition to being a catalyst for new research directions, being an 

integrator, convener, and influential mental health/public health advocate. 

Establishing a strengthened program of translational behavioral science research at 

NIMH will require special effort and incentives to overcome today's extensive structural, 

financial, and attitudinal barriers (discussed in Chapter II). NIMH needs to address 

effectively and comprehensively a host of very practical questions. These include:

• How can basic researchers at various points in their careers be attracted to 

pursue unconventional and even risky avenues of needed translational research?

• How can they be trained or partnered with others to conduct such research, and 

who will train them?
vi

• How can excellent behavioral, clinical, and services researchers be encouraged 

to collaborate in translational research projects? 

• How can reviewers with expertise in specific areas be briefed to recognize the 

best translational research?

• How can translational researchers be encouraged to consult and collaborate with 

consumers and community representatives in the design and development of 

research?

• How can such researchers find and exchange information readily with one 

another, with prospective collaborators in other disciplines, and with end-users of 

their findings--consumers, policymakers, practitioners, and payers? 

First steps in responding to these issues are addressed in Chapter IV and in the 

following action plan, submitted for consideration by the NAMHC and the NIMH 

Director: 

C. ACTION PLAN 

RECOMMENDATION 1. To establish and publicize translational behavioral science 

research as a priority funding area for NIMH and to develop a coherent strategy for its 

systematic development:

a. Develop requests for applications (RFAs) to jump-start research in each of 

the funding priority areas identified in this report, starting first with Priority 

Area 1: Basic Behavioral Processes in Mental Illness. 

b. Issue an RFA to translate basic risk and behavioral process research into 

new interventions aimed at the prevention and treatment of mental disorders 

and related problems. 

c. Develop an implementation plan for long-term development of research in the 

three priority areas of translational research.

d. Commission a "snapshot" of the current status of translational research in the 

NIMH portfolio in the research priority areas. This snapshot would serve as a 

baseline for evaluating the success of research stimulation efforts.

e. Convene workshops/conferences that bring together experts in basic 

behavioral research, clinical research, and services research, as well as 

consumers, family members, providers, health systems representatives, 

policymakers, and researchers from allied areas to identify specific areas of 

promise for translational research within the priority areas.
vii

f. Use new and existing mechanisms [e.g., research reviews, special 

workshops, RFAs, requests for proposals (RFPs), and program 

announcements (PAs)] to stimulate continuing development of translational 

research (including reinvigorating existing research initiatives in areas such 

as dissemination research, human subject protections, and services 

research) and the tools needed to conduct such research.

 

 g. Develop a plan for behavioral translational research that addresses

 communication to and among scientists as well as research dissemination to

 the public, to practitioners, and to other health care personnel. That plan

 should include articles on research opportunities in this area for publication in

 scientific journals that reach a broad audience of basic behavioral, clinical,

 and services researchers. 

RECOMMENDATION 2. Stimulate NIMH-funded research centers to provide an 

infrastructure for new research, speed the translation of findings, and encourage 

interaction across basic, clinical, and services research:

a. Offer competitive supplements (e.g., for access to patients, laboratory 

equipment, clinical trials) to existing NIMH research center programs to:

• Emphasize the integration of behavioral science in basic, clinical, and 

services research, as well as greater interaction at the interface between 

behavioral and biological science; and

• Encourage studies that apply and test basic behavioral processes in 

understanding, identifying, treating, or preventing mental disorders.

 b. Create, as needed, new research centers--with specified behavioral

 translational goals and finite life spans. 

RECOMMENDATION 3. Develop innovative approaches to supporting translational 

research:

a. Invite current basic behavioral scientist grantees to apply for supplements to 

include research on clinical populations in their studies, and current clinical 

and services research grantees to apply for supplements to include 

research on process, functioning, and/or context in their studies. These 

supplements could be competitive or administrative, undergoing an 

expedited, in-house review. 

b. Offer mechanisms for the addition of basic behavioral scientists to ongoing 

clinical and services research at academic, provider, state, and local 

settings and for the addition of clinical and services researchers and 

clinicians to basic behavioral research.

 
viii

 c. Encourage community-based research on mental disorders through small 

developmental grants to local and state governments, communities, or 

businesses working in partnership with academic researchers.

 d. Revise and expand the focus of the B/START (Behavioral Science Track 

Award for Rapid Transition) and RAPID (Rapid Assessment Post-Impact of 

Disaster) announcements to expedite the submission, review, and funding 

of initial pilot efforts for translational research in clinical settings.

e. Commission technologies, tools, and other products identified as

 high-priority needs by mental health consumers and practitioners,

 using mechanisms such as contracts and research grants through

 the Small Business Innovation Research and the Small Business

 Technology Transfer programs. 

RECOMMENDATION 4. Encourage the development, synthesis, and dissemination of 

cumulative behavioral scientific knowledge on mental illness: 

 a. Conduct behavioral research syntheses in priority areas and disseminate

them widely, in appropriately tailored formats, to various audiences of 

stakeholders. 

b. Use meetings as a strategic tool for advancing translational science, with 

a stated goal and work product, and a plan for including representation 

from all relevant stakeholder communities. 

c. Use new technologies to support virtual meetings when appropriate (e.g., 

chat rooms with consultant experts for potential applicants interested in 

designing research) and to disseminate reports of meetings. 

RECOMMENDATION 5. Train researchers at all career levels (predoctoral and 

postdoctoral students, as well as established researchers/faculty) to conduct 

translational behavioral research: 

a. Support research education programs that provide opportunities for

 basic behavioral and social science students and faculty to interact

with clinical and services research students and faculty, exchanging basic, 

clinical, and services research course work and expertise. Include courses 

on new state-of-the-art behavioral science methods and clinical nosology, 

and ideally involve faculty exemplars who combine basic behavioral 

research expertise with expertise in clinical, services, and/or policy issues. 

b. Foster individual fellowship programs and career awards that require two 

mentors, one in the basic research arena and one in the clinical/services 

research arena. By doing so, individuals at all stages of their careers would 

be encouraged to develop skills in translational research.
ix

c. Support research education programs that provide short-term training to 

enable established basic behavioral researchers to learn about clinical and 

services research, and clinical and services researchers to learn about 

basic behavioral research. If feasible and appropriate, this might include a

rotation at the NIMH intramural research program. 

d. Revise training grant policies to permit payment for teaching 

 in translational research training programs that draw faculty from

 many departments and from clinical/service settings. 

e. Establish translational research expertise banks--through the

 Internet and other mechanisms--to make expert translational advice

 available to prospective grantees and trainees (see 4(c) above). 

f. Give priority, in funding translational training grants, fellowships,

 research education grants, and career awards, to outstanding

 training programs positioned to bridge basic, clinical, and services

 research in mental health. 

RECOMMENDATION 6. Encourage fair and expert peer review of translational

behavioral research applications:

a. Prepare reviewers at NIMH and the National Institutes of Health’s (NIH’s) 

Center for Scientific Review (CSR) to assess translational research 

projects.

b. Include among the evaluation criteria for applications submitted in 

response to RFAs the expected impact of the proposed research in 

improving public health. 

c. Encourage a new orientation process that gives reviewers

 excellent syntheses of research areas, addresses the technical

 and review issues in new research priority areas, and provides

information on the current portfolio and program initiatives, and the 

programmatic objectives for moving the portfolio forward. 

 d. Ensure that for each application, reviewers collectively have appropriate

 expertise in basic, clinical, services, and other relevant research

 areas.

RECOMMENDATION 7. Facilitate appropriate and rapid funding of outstanding 

translational research: 

a. Implement a rapid revision and program review process for well-scored 

applications that can be easily corrected without requiring the delay of an 

additional submission and review.
x

b. Encourage cross-divisional technical assistance, as needed, and give 

special consideration to the funding of translational projects having both 

basic and intervention research components.

RECOMMENDATION 8. Stimulate and disseminate relevant methods to improve the 

capacity for research translation:

a. Foster the appropriate use of existing methods and the development and 

dissemination of new approaches by supporting research that:

• Develops psychometrically sound measures of basic behavioral 

processes, functioning, and context that are appropriate for use in 

clinical and service settings.

• Uses statistical sampling methodologies more comprehensively to 

enhance the external validity of research findings.

• Introduces epidemiological methods of risk identification

 into behavioral risk-factor studies.

• Adapts and develops statistical methods to facilitate the study of effect

 modifiers and individual differences as well as other approaches 

 focused on the issue of “for whom and under what co

• Encourages coordination among studies to facilitate

 research synthesis.

 b. Upgrade the quality of diagnosis by issuing RFAs or RFPs calling for

psychometrically sound clinical assessment tools for practitioners, based 

upon contemporary measurement theory. 

RECOMMENDATION 9. Improve policy decision-making processes regarding the 

delivery of mental health services and the utility of research data:

a. Support research that makes creative linkages between mental health 

services delivery questions and the behavioral research literatures of

 organization, marketing, and decision science.

b. Support research that combines state-of-the-art quantitative and qualitative 

measurement approaches to improve the quality of care.

RECOMMENDATION 10. Identify which treatments work for whom, under what 

circumstances, and why, to aid in improving mental health services and reducing 

disparities in mental health care:
xi

a. Support translational research that incorporates the theoretical 

 perspectives and methodological approaches of the social and

 behavioral sciences into research addressing fundamental 

 questions in mental health intervention and services research. 

b. Increase research on mental health disparities that includes

 contextual variables--such as ethnicity, social class, and culture.

 

RECOMMENDATION 11. Expand NIMH staffing resources by inviting behavioral 

scientists to participate in part-time consultancies or to serve as temporary visiting staff.

RECOMMENDATION 12. Monitor the effectiveness of NIMH in improving its 

translational research portfolio:

a. Develop a plan for evaluating success in implementing the three research 

and funding priorities of this report. 

b. Evaluate NIMH’s dissemination efforts to assess and improve outreach 

to key stakeholders.

Concluding Comments

The mysteries of mental illness have never been closer to solution than now at the 

dawning of the 21st century. This exciting time of discovery offers abundant 

opportunities to increase scientific knowledge about behavior and the brain in health 

and illness. That knowledge, intriguing in its own right, can and must be used to save 

and enhance the lives of millions of Americans burdened by mental disorders and 

millions more at risk of illness.

The NIMH is uniquely positioned to translate scientific achievement in behavioral 

research into clinically relevant advances. But it must deploy wisely and consistently a 

powerful array of persuasive and communicative mechanisms to create the novel and 

sometimes risky collaborations and research paths essential to translational research. 

The Behavioral Science Workgroup offers to Steven E. Hyman, M.D., NIMH Director, 

and the NAMHC an action plan outlining a practical strategy for enhancing the clinical 

contributions of behavioral science and changing the face of mental health care in 

America. 
xii

CONTENTS

EXECUTIVE SUMMARY

I. PROLOGUE..............................................................................................................1

A. Workgroup Composition and Charge..................................................................2

B. Workgroup Process.............................................................................................3

II. REALIZING THE PUBLIC HEALTH POTENTIAL OF BEHAVIORAL SCIENCE ......4

A. Current Perspectives on Behavioral Research Translation ................................4

B. Moving Forward...................................................................................................11

III. PRIORITY AREAS FOR BEHAVIORAL TRANSLATIONAL RESEARCH.................13

A. Basic Behavioral Processes in Mental Illness.....................................................15

B. Functional Abilities in Mental Illness ...................................................................22

C. Contextual Influences on Mental Illness and Its Care.........................................26

D. Concluding Comments.......................................................................... 32

IV. FROM KNOWLEDGE TO ACTION: THE NIMH LEADERSHIP ROLE....................34

A. Building the Field: First Steps ............................................................................34

B. Optimizing the Peer-Review Process ..................................................................39

C. Fostering Collaborations .....................................................................................40

D. Creating Tomorrow's Researchers......................................................................42

E. Refining Questions and Using Appropriate Methods ..........................................44

F. Communicating and Disseminating Behavioral Translational Research.............46

G. Evaluating Progress in Developing Behavioral Translational Research .............47

H. An Action Plan for NIMH......................................................................................48

I. Concluding Comments.........................................................................................53

V. REFERENCES AND FURTHER READING....................................................54

VI. APPENDICES...........................................................................................................57

A. OBSSR Definition of Behavioral and Social Sciences Research For NIH ..........57

B. National Advisory Mental Health Council ............................................................65

C. NAMHC Behavioral Science Workgroup.............................................................67

D. Roster of Consultants..........................................................................................69

E. Needed Advances in Research Methods ............................................................73
I. PROLOGUE

The dawn of a new century evokes both celebration and contemplation by the National 

Institute of Mental Health (NIMH). The care of people with mental illness has never 

been more effective or humane, thanks in part to a 50-year Federal investment in 

developing a strong scientific base for that care. Many of the major mental disorders 

are now sufficiently understood and manageable to permit many people to live and work 

as productive members of their communities despite their illness. This accomplishment 

was almost unimaginable when NIMH was founded five decades ago. The prospect of 

building on extraordinary advances in behavioral science, neuroscience, and genetics, 

combined with vital progress in research methodology, epidemiology, diagnosis, and 

treatment, promises an even brighter future for people with or at risk of mental illness. 

But one has only to pick up a newspaper or visit a local bus station, jail, or emergency 

room to realize the challenges remaining. NIMH needs to continue to explore 

intensively the basic biological, social, psychological, and environmental roots of mental 

illness. At the same time it needs to ensure that these advances are translated into 

clinically relevant, practical information, innovations, and interventions that actually can 

reduce the burden of mental illness for individuals, their families, their communities, and 

the Nation at large. 

The current social and economic burden of mental illness in America is enormous. It is 

estimated at more than $148 billion in direct and indirect costs each year, with an 

incalculable amount of suffering for a sizeable proportion of our population. A recent

international study (Murray & Lopez, 1996) of the indirect costs of illness and injury 

revealed that mental disorders account for more than 10 percent of the global burden of 

disease. Four mental disorders (unipolar major depression, bipolar disorder, 

schizophrenia, and obsessive-compulsive disorder) rank among the 10 leading causes 

of disability worldwide, with unipolar major depression leading the entire ranking. A 

public health challenge of this magnitude demands the best science we can offer to 

improve mental health and clinical care in the United States and beyond. 

This report focuses on ways to enhance the potential contributions of one specific area 

of research--behavioral science3--a bedrock of NIMH scientific activity since the Institute 

was founded in the late 1940s. Examining past achievements and future possibilities, 

the report suggests new ways to build on the Institute's rich portfolio of behavioral 

science research to reach its public health goals in the 21st century. 

Behavioral science offers critical insights into the nature of mental illness and mental 

health and the processes and interventions that can prevent illness or lead from 

 

3 See NIH definition of behavioral and social sciences research, Appendix A. Please note that this 

document uses the terms "behavioral science," “behavioral research," “behavioral science research," and 

“behavioral and social science" interchangeably, as it does the terms "consumer," "client,"
2

disorder to remission, recovery, and rehabilitation. Indeed, the basic scientific advances 

that NIMH has been funding for half a century offer ways to facilitate the translation 

process.4 It is clear, however, that behavioral science, which has yielded great practical 

benefits for education, the military and industry, as well as many health areas, has 

much more to offer in mental health. The pages to follow offer some new approaches 

for capitalizing more fully on behavioral science to understand, treat, and serve the 

millions of Americans affected by mental illness. 

A. WORKGROUP COMPOSITION AND CHARGE

As part of an ongoing review of major mental health research areas, NIMH Director 

Steven E. Hyman, M.D., and the National Advisory Mental Health Council (NAMHC) 

convened the Behavioral Science Workgroup to explore ways to enhance the field's 

mental health payoff (see Appendix B for the Council roster and Appendix C for the 

Workgroup roster). Workgroup members included a select group of NAMHC members, 

as well as researchers and advocates whose skills and knowledge complement those of 

the Council representatives. Members' expertise included social, cognitive, 

developmental, and clinical psychology, and psychophysiology, as well as anthropology, 

biostatistics, public health, and sociology. In addition, members worked in areas of 

treatment or services research covering the life span across many areas of illness, 

including depression, schizophrenia, personality disorders, anxiety, AIDS, and cancer. 

Council member Anne Petersen, Ph.D., was chosen to chair the Workgroup, and Robert 

Levenson, Ph.D., served as co-chair. 

The Workgroup was convened to address an important imbalance in the NIMH research 

portfolio: Although the Institute provides extensive support for basic behavioral 

research and for clinical and services research, there is relatively little research 

connecting these bodies of knowledge. For people with mental disorders and their 

families, this means that potentially useful behavioral science knowledge is not 

adequately mined to help them cope with illness. For behavioral science itself, it means 

that important opportunities to test theories of human behavior and expand fundamental 

knowledge are lost. 

Thus the group was charged with addressing the following key issues: 

• How can basic behavioral science inform research on the etiology, diagnosis, 

treatment, and prevention of mental and behavioral disorders? 

• How can basic behavioral science inform research on the accessibility, quality, 

and delivery of mental health services? What behavioral science findings or 

methods are particularly promising for use in clinical and services research 

 

4 Translational research in the behavioral and social sciences addresses how basic behavioral processes 

inform the diagnosis, prevention, treatment, and delivery of services for mental illness, and, conversely, 

how knowledge of mental illness increases our understanding of basic behavioral processes.
3

(including findings relevant to research participation by people with mental 

disorders or other special populations)? 

• How can NIMH encourage more systematic translation of basic behavioral 

research findings into the development of innovative research interventions that 

may ultimately improve real-world practices? 

• What barriers impede the translation process, and how can they be overcome? 

B. WORKGROUP PROCESS

The Workgroup met from March through November l999, augmenting six full meetings 

with conference calls and subgroup meetings. To enhance its perspective on current 

behavioral science opportunities and barriers relevant to mental health, the Workgroup 

invited and reviewed: 

• Recent reports and recommendations relevant to the Workgroup's task by other 

NAMHC workgroups; 

• Descriptions and critiques of the current behavioral science portfolio by NIMH 

program staff in the three major extramural research divisions, as well as 

consultations with staff in other relevant program areas; 

• Presentations by behavioral research administrators at other components of the 

NIH; 

• Discussions with researchers and representatives of key professional research 

societies, provider groups, and mental health advocacy groups (see Appendix D 

for list of consultants); and

• Comments solicited from NIMH grantees, professional societies, and from 

individuals visiting the NIMH homepage.

The Workgroup is grateful to all who enhanced its understanding of how excellent 

behavioral research can improve the lives of people now living with mental disorders 

and lessen the future toll of mental illness for our Nation.
4

 

II. REALIZING THE PUBLIC HEALTH POTENTIAL

OF BEHAVIORAL SCIENCE

The Workgroup’s task and procedures have been described above, but what was 

learned through the interviews, reading, and portfolio review? Members worked to 

discern the pattern of public health need and scientific opportunity from the information 

reviewed. Consultants to the Workgroup--including researchers, providers, consumers 

and their family members, and NIMH staff--repeatedly described the great promise of 

behavioral science and at the same time called for more multidisciplinary and 

translational research to address the needs of providers and consumers. As 

summarized below, each group brought a unique perspective, but voiced general 

agreement on the need for and difficulty in achieving greater linkage across research 

fields and between basic and clinically oriented mental health research. All agreed that 

the representation of such research in the current NIMH portfolio should be increased. 

Many suggested why these are difficult areas to develop and offered steps NIMH can 

take to overcome current barriers.

A. CURRENT PERSPECTIVES ON BEHAVIORAL RESEARCH TRANSLATION

1. Consumers and Advocates

Behavioral technologies have improved the quality of life of people living with cancer, 

AIDS, heart disease, and substance abuse. Although people with mental disorders and 

their advocates also have benefited from some behavioral research advances, they 

want more extensive and more immediate benefits. Long-term investments in basic 

research, both behavioral and biological, are essential for progress toward the goal of 

eventually conquering mental illness. But consumers and family members want a 

greater investment directed at improving their quality of life now. They want to reclaim 

their personal, occupational, social, and recreational goals. And they want treatments 

and services tested against these real, meaningful, and behaviorally quantifiable 

objectives. The box below, "What People with Serious Mental Illness and Their 

Families Want from Behavioral Science Research," indicates some of the issues such 

research might illuminate.
5

What People with Serious Mental Illness and Their Families Want from

Behavioral Science Research

The National Alliance for the Mentally Ill (NAMI), a grassroots organization of consumers with serious 

mental illnesses, their family members, and advocates, was asked to identify priority areas for individuals 

with severe mental illnesses that would benefit from behavioral science research. Dr. Laura Lee Hall, 

NAMI's Director for Research, noting that behavioral and social research is essential to understanding 

and improving the treatment and lives of children and adults with severe mental illnesses and their 

families, proposed the following areas of interest:

• Assessing therapeutic processes and outcomes

• Understanding the basic processes underlying family support, easing the burden of care, 

 and exploring ethnic and other group differences in these processes 

• Developing rehabilitation tools that speed and enhance recovery 

• Discovering techniques to improve adherence to treatment and rehabilitation plans

• Exploring behavioral approaches for managing the side effects of medications 

• Refining approaches for understanding and treating co-morbid substance abuse

• Recognizing the early signs of relapse and preventing the downward spiral for individuals 

 with mental disorders

• Clarifying forensic issues of culpability and consent for people with fluctuating cognitive capacity

• Evaluating educational interventions for children with severe mental illnesses

• Preventing suicide by identifying how providers or family members can intervene

• Informing decisions about housing placements for individuals with severe mental illnesses returning 

to communities 

2. Payers

Leaders in managed care organizations (MCOs) and state agencies providing and 

reimbursing care in large service systems must make difficult decisions regarding 

health/mental health care, often with insufficient hard evidence. They want to know 

what health goals can be reached at what cost, as well as the costs of not reaching 

them. Typically, their decisions must focus on which interventions will work for the 

largest proportion of their population. 
6

Some representatives observed that because few of the available research findings 

appear applicable to their settings and clients, it has been difficult to see how a 

nontargeted approach to behavioral research could lead to real advances in clinical 

care. They also reported little confidence in investing time or training funds to 

implement new treatments or services without compelling research evidence obtained in 

settings and with clients like their own. Some potential contributions of behavioral 

science research to today's health care systems are described in the box below. 

What Health Care Delivery Systems Need from Basic Behavioral Research

Council member Mary Durham, Ph.D., a services researcher and representative of a nonprofit MCO, 

identified a number of research areas in which behavioral science can contribute to MCOs and other 

health care delivery systems. These include:

• Basic behavioral research is needed to identify ways to improve patient adherence to and provider 

provision of treatment to improve clinical care;

• Clinical planners have an urgent need for behavioral interventions to enhance psychological and 

physical functioning, and to interrupt or reduce the adverse health consequences of stress; 

• Health plan leaders need behavioral principles for stimulating and maintaining organizational change; 

and

• Evidence-based behavior-change techniques are needed to aid clinicians in enhancing healthful 

behavior and reducing unhealthful behavior. 

3. Practitioners

Like some payers, some clinical providers felt that they were not necessarily well 

represented in current research related to services and health care policy. A particularly 

salient issue is the perceived lack of fit between research-based treatment guidelines 

and the clinical settings and consumer groups who were intended to use those 

treatments--a factor likely to affect utilization. Many reported that certain guidelines set 

conditions for duration and intensity of treatment that would not be permitted within their 

settings due to costs. Another comment was that the research findings had little to offer 

on the most complex cases with overlapping symptoms, physical illnesses, substance 

abuse, and difficult life circumstances. However, these concerns could be addressed, 

some felt, if practitioners had a larger role in developing and conducting generalizable 

research. One group of practitioners gave the Workgroup the following suggestions:

• Demonstrate the effectiveness of evidence-based treatment rules in care settings 

and with clients similar to sites where the rules are to be implemented.

• Document more clearly what interventions work for specific consumers in specific 

settings.
7

• Clarify motivational markers that might predict the clients who would stay with 

specific treatments or service options.

• Recognize that "free time” does not exist in clinical settings; do not expect 

practitioners or service sites to donate time, effort, or resources for research. 

• Clarify for practitioners involved in difficult forensic issues (e.g., to treat or not to 

treat, determining abuse status, consent for treatment, potential for violence) 

what empirically validated decision rules exist to help make these determinations. 

• Define and strengthen clinical decision-making processes. 

• Discover optimal ways to diffuse evidence-based treatments and clarify the 

factors affecting clinicians' receptivity to treatment guidelines and new 

approaches to treatment (e.g., assess the incremental value of having the 

providers involved in developing the diffusion strategy).

4. Researchers

Researchers suggested diverse ways to encourage the translation of behavioral 

science. Some felt that NIMH should let science evolve with little external direction 

because continuing support of basic research should yield incremental gains that would 

gradually advance our understanding of mental disorders. Others argued for identifying 

and targeting support for research at the intersection between the most promising 

behavioral science and the greatest clinical/social need. Researchers from both 

orientations agreed that many critical barriers to research translation are embedded in 

the structure of the academic research community and reflected at NIMH. These 

difficulties, most of which are not specific to behavioral science, include:

• There is growing disciplinary fragmentation and specialization, and unfamiliarity 

with the language, values, and methods of other disciplines. 

• Basic, clinical, and services researchers do not typically work together, and 

moving to bridge this gap is not easy.

• There is a split in training between research with clinical versus normal 

populations (often in separate departments and physical loci).

• Clinical populations are often inaccessible to basic researchers. 

• The academic incentive system typically rewards productivity in traditional 

disciplinary areas--and in traditional disciplinary publications--and has few 

incentives for bridging research areas or fields of study.

 

• Training programs rarely span translation from basic to clinical research, and 

there is little, if any, exposure to services research. 
8

• Many basic behavioral scientists are unaware of the interesting basic research 

issues and opportunities posed by mental disorders.

• Clinical and services researchers may find it difficult to access the current 

behavioral science knowledge base to inform their research.

• Some basic behavioral scientists are unaware of how to engage individuals with 

mental disorders in the research effort. 

Basic behavioral scientists suggested to the Workgroup a number of reasons for their 

own personal reluctance to conduct translational research or to encourage their 

students to do so. Some new investigators expressed concern about what they saw as 

significant barriers and disincentives to beginning a career in patient-oriented research. 

These include: inadequate knowledge about the nature of mental disorders; concern 

about funding stability and resources; uncertainty about how to recruit participants and 

engage clinical colleagues to collaborate, and about where "hybrid" research would be 

published; and doubts about the applicability of basic research to clinical issues. Other 

important barriers they mentioned include: their lack of exposure to the clinical 

literature; fear of appearing "amateurish" to grant reviewers in a new research area; and 

lack of methods experts or individuals who can cross lines among behavioral, 

physiological, neural, and clinical research. 

One of the most surprising barriers cited by these researchers was their lack of 

awareness of specific NIMH translational research program announcements (PAs) (e.g., 

requests for research on informed consent, behavioral science in services research, 

and method development),5 even though they had been published in the conventional 

dissemination outlets. The lack of effective communication to potential applicants is a 

significant obstacle that needs to be addressed. 

5. Research Administrators

a. Current Status of NIMH Behavioral Research Programs 

NIMH program staff gave the Workgroup an informal "snapshot" of the current NIMH 

behavioral research portfolio that included its strengths, its shortcomings, and its future 

translational possibilities.6 Their comments made clear that during the past 4 years, 

NIMH research priorities have undergone a transformation under the direction of 

Dr. Steven Hyman. NIMH is placing greater emphasis on the public health relevance of 

its research and on the role of consumers and advocates in shaping the Institute's 

 

5

("Research on Ethical Issues in Human Studies"; "Dissemination Research in Mental Health"; and 

"Integrating Mental Health Services Research and Behavioral Science"--see NIMH Website at 

http:nimh.nih.gov/grants/pamenu.cfm for full announcements.) 

6

 NIMH program staff provided abstracts of all the Institute's grants (except for neuroscience and AIDS) 

and assessed their individual research program areas. These assessments included a program 

synopsis, a description of its payoff to date, and a description of research gaps as well as opportunities 

for further research and translation. 
9

research agenda. (Their recent inclusion in treatment and services research review 

groups is but one indication of this shift.) This change means looking at the Institute's 

research portfolio not only from the perspective of scientific readiness and opportunity, 

but also with an eye toward clinical and public health need for knowledge and innovative 

applications to clinical care. This perspective already was familiar to NIMH staff and 

grantees concerned with behavioral science research in the area of HIV/AIDS research. 

The creation of this Workgroup was intended to reflect and accelerate this change in 

perspective throughout NIMH. 

The Institute also has undergone a significant reorganization of its funding divisions to 

better reflect and achieve these new priorities. Each of the three extramural research 

divisions at NIMH7 funds behavioral research, which forms a substantial part of the total 

NIMH research portfolio. In the aggregate, behavioral and social science research8

represents an estimated 34 percent of total NIMH FY 1998 funding (including AIDS 

research). However, across the three major NIMH extramural research divisions, there 

is a great need to close the gaps separating basic science, clinical research, and health 

services research; as well as those separating process from outcome research, and 

consumer needs from the foci of scientific research. Three prime problem areas 

identified by staff include: 

• The substantive and methodological behavioral science base is being underused 

in developing new diagnostic, prevention, treatment, and service strategies. 

• Until quite recently, a strong emphasis on diagnosis and acute treatment drew 

attention away from rehabilitation, maintenance, and the impact of mental illness 

on daily lives. 

• Relatively few researchers have responded to recent NIMH efforts to stimulate 

translational research through PAs directed at behaviorally oriented translational 

research. 

b. Potential Strategies for Developing NIMH Behavioral Translational Research

Despite the difficulties of stimulating behavioral translational research, programs have 

successfully developed and/or used behavioral research knowledge to illuminate and 

address very concrete and complex clinical problems. A particularly dramatic example 

is the work of the Institute's AIDS research program. Developed over 16 years, this 

program has given rise to effective research-based behavioral preventive interventions 

for HIV and has built from scratch a respected cadre of behavioral researchers who are 

leaders in the conduct of translational studies. In 1983, when the NIMH AIDS research 

program began on an annual budget of less than $200,000, there were no behavioral 

researchers with specific expertise in HIV prevention, and no research focused 

specifically on high-risk sexual behavior. Relatively few behavioral researchers were 

 

7

 Division of Neuroscience and Basic Behavioral Science; Division of Services and Intervention Research; 

and Division of Mental Disorders, Behavioral Research and AIDS (DMDBA).

8

 See Appendix A: OBSSR Definition of Behavioral and Social Sciences Research.
10

doing health-related applied studies, and even fewer services researchers were 

available to study the efficacy of HIV interventions in real-world settings. To build a 

clinically applicable research program on HIV/AIDS prevention, it was necessary to find 

and pool the relevant knowledge of diverse researchers and attract and train them to 

conduct studies in the nascent, high-risk, and highly stigmatized area of HIV prevention. 

The program's budget has since grown to almost $130 million a year, and the AIDS 

behavioral prevention approaches it has developed are now being assessed in largescale intervention studies in selected sites throughout the world. 

The NIMH Center for Mental Health Research on AIDS has demonstrated that basic 

behavioral research can be translated into effective real-world interventions to prevent 

the spread of HIV. It also provides telling lessons in how to build over time an 

interdisciplinary field to fulfill a public health mission. Although some important facets of 

the Center's experience may be unique, many aspects appear to be broadly applicable 

to other kinds of NIMH research. The NIMH AIDS research model, although largely 

derived from trial and error, can now be seen as a phased approach to program 

development. [Indeed, one can also point to NIMH’s genetics effort as a successful 

example of a phased strategy (National Institute of Mental Health Genetics Workgroup, 

1998).] 

The key components for building a behavioral research field with clinical impact appear 

to be these: 

• Widespread recognition of a pressing public health need;

• Clear statement of program goals developed with all key stakeholders (e.g., 

develop effective behavioral interventions for HIV prevention);

• Intensive sponsorship of literature syntheses to assess the state of knowledge, 

encourage information exchange, and stimulate research and training interest;

• Use of scientific meetings to encourage collaborations/cooperation across types 

of basic and applied research, scientific disciplines, 

consumer/researcher/policymaker perspectives, and Federal agencies; 

• Stable and appropriate funding of the types of research targeted in the 

announcements--primarily RFAs and PAs--to attract and keep researchers of 

quality;

• Development of qualitative and quantitative tools needed to initiate and advance 

the research field;
11

• Well-trained, energetic staff to work with and encourage the participation of 

potential grantees and trainees;

• Appropriate scientists on review committees who can uphold high standards for 

research excellence while maintaining realistic expectations for research design 

and methodology in developing clinical/applied/services research areas; 

• Creation and support of time-limited multidisciplinary research centers to foster 

integrative research and provide a training ground for developing future 

researchers and research;

• Development of multiple levels and types of training support to stimulate career 

development in essential new multidisciplinary translational areas;

• Use of a knowledge diffusion model both in the design and in the dissemination 

of interventions involving key leaders in the community; and

• Long-range, systematic program planning to identify new opportunities and to 

evaluate program progress.

 

With long-term nurturance by a comprehensive program such as this, many of the usual 

barriers separating basic research from clinical and services research can be overcome. 

The NIMH AIDS research program has had a palpable impact on the careers of many 

basic behavioral scientists, encouraging them to broaden their perspective beyond 

basic animal research or studies of normal human populations to include observational 

and intervention studies of ill people or people at high risk of illness. Indeed, some rare 

individuals move comfortably back and forth or in parallel across basic and 

clinical/services research studies. As one such researcher described this research 

synergy: 

I am particularly pleased that our program of research does not stop with these kinds of 

field experiments. The work itself feeds back to our original theoretical ideas. For 

example, we have begun to understand why preventive health messages framed in 

certain ways motivate different behaviors. Most decision theorists are not especially 

focused on mechanism, but we are able to isolate the importance of changes in 

perceived risk and shifts in anticipated emotions as possible mediators of behavior 

change. I've found it very rewarding to be able to conduct research in an area that allows 

me to address theoretical questions in social psychology while confronting real problems 

of social and personal relevance.

B. MOVING FORWARD

The Workgroup has been asked essentially how to increase the amount and speed of 

clinical payoff from behavioral research. The broad answer is to apply the lessons 

learned from the many stakeholders cited above and from successful translational 

research programs in developing new clinical applications of basic behavioral research 

to improve all aspects of mental health care. To do so, NIMH needs to:
12

• Clarify its goals for behavioral translational research; 

• Initiate a strategic, phased approach for identifying and developing priority 

research areas for mental health translational research with all stakeholders; and

• Enhance infrastructure and training capacity for such research and ensure its 

long-term continuity and coordination. 

A fundamental principle in implementing these three activities should be: Let the 

intended end-users of translational research--patients, providers, payers, and 

policymakers--join as expert partners in setting the research agenda and forming 

research questions. Doing so provides invaluable benefits for the total research 

enterprise: it grounds the research in the realities of public health need; it encourages 

solutions to practical problems in clinical care; and it paves the way for greater longterm acceptance and application of research-based innovations.

The Institute clearly has the power to foster greater translation of behavioral science 

knowledge; it needs a plan for doing so. Accordingly, the Workgroup members have 

synthesized from many resources broad guidance for a relatively long-term process of 

research transformation at NIMH. First steps articulated by the Workgroup can and 

should be initiated immediately.

The chapters to follow offer a coherent approach for developing new clinical 

applications of basic behavioral research to improve all aspects of mental health care--

including diagnosis, treatment (psychosocial, pharmacological, and somatic), 

rehabilitation, prevention, and services delivery. Research using basic behavioral 

principles and ideas to address provider, payer, and consumer issues offers a vital way 

to improve the lives of people with mental illness. But it has even more to offer. 

Designed well, translational research also can test the validity and generalizability of 

basic behavioral principles themselves and offer clues to their refinement. Once this 

process is underway and some of the best behavioral scientists are working on clinically 

relevant problems, many benefits and applications are likely to emerge that cannot now 

be specifically anticipated.

Chapter III suggests some of the exciting ways in which behavioral research can 

address pressing issues confronting people with mental illness and those who provide 

and support their care. Chapter IV reflects the Workgroup's judgment of how to 

capitalize on those research opportunities to move more NIMH behavioral research 

from promise to practice. 
13

III. PRIORITY AREAS FOR BEHAVIORAL

TRANSLATIONAL RESEARCH

The long-term NIMH investment in behavioral science research has yielded a

wealth of opportunities for developing and applying behavioral science knowledge and 

methods to benefit clinical, intervention, and services research and, ultimately, clinical 

care. These range from studies that clarify basic brain function to studies that enhance 

understanding of the causes and prevention of violent behavior, to epidemiological 

research and health services research studies that inform the organization, financing, 

and delivery of public and private mental health services. 

All aspects of basic behavioral science can contribute to improved clinical

practice. The excitement and importance of these areas were reviewed in the 1996 

NAMHC report Basic Behavioral Science Research for Mental Health: A National 

Investment. In brief, potential clinical gold resides in substantive areas of basic 

behavioral research that include:

• Affect /motivation/emotion/personality;

• Perception/memory/learning/reasoning/decision making;

• Social processes/environmental factors;

• Behavior change;

• Life span development;

• Cultural studies and ethnography; and 

• Animal and comparative behavior. 

Basic behavioral science promises to contribute to the development of a new generation 

of therapeutic and preventive interventions for many mental illnesses. For example, a 

program of research on self-concept discrepancy and depression shows how research 

can progress from theory to laboratory studies to clinical application (see box below, 

"From Campus to Clinic: Developing a New Psychotherapy for Depression"). It 

provides an excellent illustration of how basic behavioral science can contribute to 

clinical practice and intervention. 
14

From Campus to Clinic: Developing a New Psychotherapy for Depression

Self-System Therapy is a very new, brief structured psychotherapy for depression that is currently being 

tested through an NIMH-sponsored randomized clinical trial. This therapy is an outgrowth of very basic 

behavioral science studies and theories relating to how people regulate their thoughts and moods.

One foundation for this research is the basic research finding that normal people react with negative 

affect (such as depression or anxiety) to certain self-discrepancies (e.g., between their perceptions of 

who they are vs. their "ideal" or "ought" selves). This finding and others contributed to the hypothesis that 

when people are chronically aware of these discrepancies, they are more likely to experience repeated 

bouts of negative affect. Furthermore, it seemed possible that this chronic accessibility, in combination 

with other risk factors, might increase the risk of more serious emotional problems, such as depression.

In 1996, Timothy Strauman delineated these various risk factors in a model of depression involving the 

psychology of self-evaluation (Strauman, 1996). This model described how predisposing factors (e.g., 

individual differences in the intensity or regulation of emotional states, traumatic early life events) might 

combine with factors that influence the development of self-representations (e.g., personality structure, 

parenting styles) and factors triggering negative self-evaluation (e.g., self-discrepancies, current life 

difficulties) to lead to a final common pathway to depression.

Strauman and his colleagues are now establishing the final link from the model to a treatment intervention 

for depressed patients. They had previously demonstrated that both cognitive-behavioral therapy (CBT) 

and interpersonal therapy (IPT)--two effective treatments for mild to moderate clinical depression--

decreased self-discrepancies in clinically depressed and anxious individuals. Now, studying patients with 

major depressive disorder, they are evaluating the impact of Self-System Therapy, an intervention more 

specifically targeted to two main sources of distress: 1) problematic self-beliefs (i.e., particular beliefs, 

goals or standards used in self-evaluation that conflict with other important beliefs); and 2) the tendency 

to invoke ideal or ought standards irrespective of the demands of a given situation.

This line of research is exploring, among other questions, whether altering specific self-beliefs can 

change the onset or duration of depression or anxiety. New findings may also shed light on which active 

ingredients account for the success of CBT and IPT--an important question for future intervention 

development.

Applied research areas with relevance to mental health--such as health psychology/ 

behavioral health, organizational change and management, communications and 

persuasion, and education--offer still more avenues for improving clinical care. In 

addition, powerful behavioral science technologies are available in areas such as 

measurement, testing, survey techniques, observational methods, statistical methods, 

and research analysis. 

Notwithstanding the focus of this report on a single but very broad research area, it is 

important to remember that no single discipline or cluster of disciplines is sufficient to 

unravel the mystery of mental disorders, their prevention, and treatment. One of the 

great lessons of late 20th century research in mental illness is the necessity for 

intellectual ecumenism in an age of overspecialization. Basic behavioral research, 

neuroscience, pharmacological research, and genetic science--individually and in 

various combinations--have enormous potential to contribute to the understanding, 

prevention, and treatment of mental illness. The challenge to NIMH leadership is to 
15

orchestrate the individual strengths and characteristics of these fields into a coherent 

understanding of these extremely complex disorders of molecule and mind, of brain and

behavior. For example, research on the neuroscience and genetics of mental disorders 

needs to be informed by state-of-the-art concepts, measures, and methods of basic 

behavioral research if it is to contribute fully to an understanding of psychopathology.

Progress in translating behavioral science advances in knowledge into meaningful 

advances in clinical care requires building a research environment in which 

collaborations across disciplines are normal, not exceptional. Realizing the enormous 

potential of such research requires challenging the trend toward increased disciplinary 

specialization by encouraging greater collaboration of basic behavioral scientists with 

their counterparts in biologically and clinically based disciplines, an issue addressed in 

Chapter IV.

 

In this chapter, the Workgroup highlights three specific areas of study in which the push 

of research progress converges with the pull of public health need (i.e., the real-world 

needs of consumers, practitioners, payers, and policymakers) to create prime targets for 

intensified study. These priority research areas are critical starting points for progress 

in translational science because they are at the interface of what end-users have 

identified as important and what behavioral science researchers regard as areas of 

opportunity. They offer the prospect of conducting exciting research, advancing 

scientific understanding of behavior--in health and in illness--and improving the mental 

health of our Nation. 

A. BASIC BEHAVIORAL PROCESSES IN MENTAL ILLNESS

PRIORITY AREA 1. Understand how basic behavioral processes (e.g., cognition, 

emotion, motivation, development, personality, social interaction) are altered in 

mental illnesses, how these processes relate to neurobiological functioning, and 

the implications of these alterations for etiology, diagnosis, course, prevention, 

treatment, and rehabilitation.

• Develop reliable and valid methods for assessing these basic behavioral 

processes as part of clinical diagnosis. 

• Assess how preventive, treatment, and rehabilitative interventions affect these 

basic behavioral processes. 

• Evaluate these basic behavioral processes as indicators of risk for the 

development or exacerbation of mental illness.

• Combine basic behavioral research with neuroscientific, pharmacological, and 

genetic research to produce an integrated approach to understanding, 

preventing, and treating mental illness. 
16

a. Issue: Many of the most debilitating and problematic aspects of mental illness (for 

consumers and their families, and for clinicians) are characterized by changes in basic 

behavioral processes. Assessing these changes--for which many sensitive measures 

have now been developed by behavioral scientists--offers a promising complement to 

traditional category-focused diagnostic systems. Further, in combination with other, 

more biological assessment approaches, these assessments may offer new insights 

into the functional and structural neurobiology of mental disorders. 

An extensive body of behavioral science has identified the specificity and variability of 

basic behavioral processes in normal populations and has developed a range of 

methodologies and technologies for such research. This work now needs to be 

extended to include clinical populations, both to test the generalizability of the basic 

findings and to clarify how--and in which dimensions--people with certain illnesses or 

symptoms differ from the population at large. Applying this knowledge and these 

methodologies to clinical populations can lead to refined diagnosis, better measurement 

tools, and more precisely identified points of intervention to prevent or lessen symptoms 

and improve functioning. It also will increase understanding of how behaviors, 

symptoms, and disabilities actually cluster across disorders. 

b. Research Avenues9: Some important research needs and opportunities within 

Priority Area 1 are described below. 

• Memory and Emotional Processes in Schizophrenia

As basic behavioral researchers have worked to refine and differentiate 

psychological functions and to understand their interrelatedness, they have 

developed new methods that are being applied in psychopathology research. For 

example, the question of whether people with schizophrenia have memory deficits 

has led to an examination of various types of memory in such patients. Using 

methods developed by basic behavioral researchers (Cohen & Faulkner, 1988; 

Conway & Dewhurst, 1995), studies of individuals with schizophrenia recently 

revealed deficits in their episodic memory, that is, memory for personal events; 

these individuals find it difficult to recall and review specific experiences (Danlon, 

Rizzo, & Bruant, 1999). This research on memory may have implications for 

designing cognitive rehabilitation programs. Testing for deficits and preserved or 

 

9

Note that for this priority area, as well as the following two, the examples provided are illustrative and

not exhaustive; many other lines of research are germane as well. In all of these priority areas, the 

examples given are drawn both from the "push" of basic research and from the "pull" of public health 

need. Some represent relatively well-developed areas in which potential links to specific mental illness 

already are evident but in need of further refinement. Others represent promising lines of research whose 

relevance to specific mental disorders and their diagnosis, prevention, and treatment remains to be 

explored. Still others--particularly in Priority Areas 2 and 3--are largely statements of research need. But 

above all, the examples are intended to highlight the great promise of applying basic research to 

problems of mental illness. The Workgroup's intent is to encourage researchers to consider making such 

bridges in other domains not yet considered or explored. 
17

enhanced process may form the basis for the next generation of diagnostic and 

rehabilitative approaches.

Basic research also is relevant to studying multiple aspects of the emotional system 

(emotional experience, emotional expression, emotional physiology) in 

schizophrenia. People with this disorder have both "positive" symptoms 

characterized by excess (e.g., hallucinations, delusions) and "negative" symptoms 

characterized by deficit (e.g., social withdrawal, poverty of speech). A new line of 

basic research on the emotional system in such individuals is challenging previously 

held beliefs about the dampening of emotion in schizophrenia (Kring & Neale, 1996). 

This research has revealed that, in response to viewing emotionally charged films, 

people with schizophrenia do indeed show markedly less emotional facial behavior 

than controls, a finding that is consistent with descriptions of emotional flatness in 

the disorder. However, when the other components of the emotional response to 

these films were examined, a much more complex picture emerged. The subjective 

emotional experience reported by people with schizophrenia was comparable to that 

of controls, but the ill individuals had the same or greater levels of autonomic 

nervous system response. 

Thus, while showing little outer manifestation of emotion and seeming emotionally 

lifeless and constricted, such patients may actually be experiencing a great deal of 

emotion. These findings have enormous implications for understanding, treating, 

and dealing with the disorder. They suggest that at least some people with 

schizophrenia may live in a world where their emotions are constantly misread and 

misinterpreted by others, a particularly cruel consequence of the disease. The 

findings also have important implications for research on the biological 

underpinnings of schizophrenia. The likelihood that emotional dampening in 

schizophrenia is limited to facial behavior points toward very different underlying 

neural mechanisms than would be implicated if all aspects of emotion were 

dampened. 

• Self-Awareness and Depression

Another productive area for translational research concerns the interaction of selfawareness and depression. Recent research suggests that people prone to 

ruminate in response to their negative emotions--a characteristic more prevalent 

among women than men--are particularly at risk for more severe and prolonged 

distress following negative life experiences. Their ruminative style increases the 

accessibility of negative thoughts and memories, which exacerbate depressed mood 

(Lyubomirsky & Nolen-Hoeksema, 1995). The greater prevalence of clinical 

depression among women may stem in part from rumination effects that amplify 

symptoms and extend depressive episodes. Clinical research suggested by these 

findings includes studies of the potential efficacy of depression treatments that 

distract individuals from their self-absorbed thoughts long enough for their 

depressed mood to be relieved or that encourage people to believe that they can 

change depression-inducing situations. 
18

Understanding cognitive and emotional abilities--their boundaries and constraints, 

the mechanisms that underlie them, how people use them, and what they can do to 

change them--is a crucial task for researchers dedicated to improving mental health. 

However, the next generation of behavioral science research can and should go 

beyond simply studying in symptomatic or ill individuals those phenomena found in 

normal subjects; basic researchers also need to develop hypotheses predicting 

which processes would be preserved, hindered, or atypical when certain symptoms 

or disabilities are present. Empirically testing these predictions will be the sharpest 

test of understanding which processes are involved or affected and how to correct 

them to improve mental health. 

• Measurement Theory and Clinical Diagnosis 

Great strides have been made over the last decade in developing instruments to aid 

in detecting and diagnosing mental disorders. Although these measures have 

provided a common language for researchers and, in some cases, for 

reimbursement policy, developing and improving tools for research and practice 

remain important translational goals. Incorporating newer methodologies developed 

within the broad domain of the quantitative and measurement sciences could 

improve the precision of diagnosis and conceptualization of mental illness, shorten 

testing time for patients, and strengthen the assessment of patient recovery. Three 

examples of potential applications to clinical diagnosis and practice follow: 

• Developing multi-dimensional measurements of functioning that complement 

traditional symptom-based diagnostic systems could help to refine 

understanding of treatment outcomes and differentiate individuals who are 

currently grouped within a single diagnostic category. For example, separate 

assessments of schizophrenia along dimensions of social interactions, 

attentional deficits, and neurophysiological abnormalities could both provide a 

more comprehensive evaluation and suggest potential areas of treatment 

emphasis. Similarly, developing measurement systems that blend symptombased indicators with process-based indicators would allow for a richer 

understanding of the individual client, thereby allowing finer grained treatment 

approaches and leading to better scientific understanding of the complex 

interplay of process and symptom.

• Computer adaptive testing approaches (described below) could be modified 

to address the difficult problem of diagnosis. Adoption of these approaches 

(already widely used in a number of educational testing domains ranging from 

ability assessment to tracking outcomes of interventions for reading 

disabilities) might significantly reduce the amount of testing time required to 

arrive at a diagnosis, or, perhaps more important, provide an estimate of an 

individual's functional level. The technology of computer adaptive testing is 

well established, but has not yet been rigorously explored as a technology for 

clinical assessment in the mental health domain.
19

Using these approaches, an assessment begins with an estimate of the 

individual’s level on a trait or behavior (e.g., a small number of probe items). 

By sequentially presenting questions from an item pool ranging in level of 

intensity or difficulty, the assessment progressively focuses on a level 

appropriate for the individual. For example, if the assessment were focused 

on phobias, the questions might involve behaviors related to limits in daily 

functioning. Starting with an initial estimate of the average level of restriction, 

the person would confirm or deny this level of disability. A confirmation would 

be followed by a question addressing still greater severity. This process 

would continue until an estimate of the functional level of the individual, with 

predetermined precision, is obtained. This provides a tailored assessment, 

and only the number of questions needed to obtain an estimate of prespecified accuracy would be asked. 

• Item response theory (IRT) refers to the development of test questions 

systematically varying in “difficulty” in order to measure individual differences 

in ability. Such carefully crafted and tested questions would be helpful to 

patients and clinicians, as well as researchers, in two ways. The first would 

be to develop new and better scales of "wellness," "functioning," 

"satisfaction," or similar important constructs. A second use would be to 

establish banks of items with similar characteristics, which could be used 

interchangeably in repeated assessments of the same individual over time to 

track the course of recovery without the identical item having to be used 

repeatedly. These applications could improve the ability to monitor change by 

assessing very fine differences in functions or symptoms during the course of 

treatment and recovery.

• Biobehavioral Research and Mental Illness

The contributions of behavioral science to mental health can be multiplied many 

times over through collaboration with other vital areas of research. For example, 

mental health research is likely to benefit exponentially from advances at the 

interface of neuroscience, genetics, and behavioral science that can clarify how 

behavioral and biological factors interact in the etiology, course, and amelioration of 

psychopathology. Examples of research opportunities at this interface are described 

below.

• Brain Plasticity and Behavior

As research and clinical interest expand from acute control of symptoms to 

include longer-term issues of rehabilitation or recovery, there is growing 

interest in recovery of brain functioning. The term "brain plasticity" refers to 

changes in the structure and functioning of the brain, whether through 

development, learning, or recovery from injury. Researchers examining brain 

plasticity have noted that "experience produces multiple, dissociable changes 

in the brain including increases in dendritic length, increases (or decreases) in 
20

spine density, synapse formation, increased glial activity, and altered 

metabolic activity" (Kolb & Wishaw, 1998). The size of ventricles (open, fluidfilled areas) in the brain--a measurement that is used as an index of brain 

dysfunction in several disorders--has been found to change over time with 

changes in experience and nutritional status. Several studies of 

psychotherapy outcomes have found brain functional changes that are 

associated with positive behavioral outcomes (Baxter et al., 1992). Research 

in this area, typically conducted by basic behavioral researchers often in 

cooperation with psychopathology researchers, is still at the early stages of its 

development in clinical populations and needs to be expanded. 

• Biobehavioral Development and Mental Disorders

Behavioral science offers a rich description of risk factors associated with the 

onset of mental disorders at multiple levels of analysis/environment. Normal 

behavioral development (cognitive, linguistic, motor, emotional) has received 

extensive study, and the behavioral course of some child psychopathologies 

has been described (e.g., conduct problems, autism). Complementing this 

area of research progress is a young but growing research area focused on 

genetic control of the unfolding of brain structure and system development. 

Also evolving rapidly are visualization technologies (e.g., functional magnetic 

resonance imaging--fMRI) that provide unprecedented access to the living, 

behaving, developing brain, even as recently reported, while a fetus responds 

in utero to its mother's voice. At present, however, these are all too often 

separate fields of study (e.g., neurodevelopment, behavioral development, 

and developmental psychopathology/psychiatry) with little crosstalk and with 

separate literatures, separate schools (medical vs. graduate), and distinct 

conceptual frameworks (medical model vs. transactional). The potential gains 

in developmental understanding and in clinical capacity to avert or divert 

adverse developmental trajectories demand the Institute's best efforts to 

stimulate greater collaboration and cooperation across these disciplinary 

lines. 

 

• Genetics and Behavior

Mental disorders are extremely challenging to genetic researchers because 

they do not stem from errors in single genes. In addition, both genes and 

environment appear to be complexly and interactively involved in the 

development of mental disorders, perhaps with multiple components of each. 

Furthermore, a mental disorder such as schizophrenia may be at the most 

severe end of a continuum of schizophrenias that include, in descending 

severity, schizoaffective disorder, schizophreniform disorder, schizotypal 

personality disorder, and possibly other variants. Growing research evidence 

suggests that other major mental disorders may follow the same pattern. 

Thus, collapsing multiple diseases or degrees of illness into a single category 

makes the search for genetic influences much more difficult, since each 
21

subset of a disease may have different genetic influences. A gene hunter 

may miss an important lead because it is not seen in all members of the 

affected population. 

Circumventing this problem requires careful behavioral and biological 

descriptions of the behavioral phenotypes of specific subsets of mental 

disorders (how the mental disorders are expressed in individuals) so that 

these subsets can be identified genetically--a vital task for behavioral 

researchers. Vital, too, is the application of behavioral technologies from 

psychometrics and behavioral genetics to study sources of genetic and 

environmental variation and to dissect and understand the embedded 

phenotypes. Therefore, very fine analysis of hypothesized phenotypes is 

required so that appropriate subsets are defined and genetically linked. 

Understanding the behavioral phenotype also is critical in the area of basic 

genetics, where researchers are testing the role of given genes through 

powerful "knockout" technologies that genetically alter animals to provide 

models of presumed genetic deficits. This research has revealed critically 

important understandings of disease processes at the cellular and molecular 

levels. However, when attempting to find the genetic basis for certain 

enduring behavioral dispositions that may confer or reflect susceptibility to 

mental disorders, identifying specific behaviors associated with specific 

genetic manipulations is no easy matter. Analyzing the changed behavior of 

genetically altered species requires the collaboration of experts in animal 

behavior who bring measures and paradigms developed to understand

behavior in genetically normal animals, as well as extensive knowledge of 

species-specific social and sexual behaviors that might be disrupted.

Genetic manipulation is but one of many potential techniques for creating 

animal models of mental disorders. Because providing an overarching model 

of a mental disorder has proved difficult, researchers need to begin with 

partial models that can aid significantly in the clinical research enterprise. 

Animal research and comparative behavioral research have provided some 

partial animal models that are useful for research, such as dogs with acral lick 

syndrome, a compulsive licking behavior that resembles behaviors seen in 

obsessive-compulsive disorder, and which, like them, responds to 

medications such as fluoxetine (Prozac). Again, progress in such research 

requires, at a minimum, a pooling of behavioral and biological expertise. 

In conclusion, the most tantalizing biobehavioral findings would be those in which 

convergent data across multiple fields and levels of analysis provide a new empirical 

nexus for understanding specific mental disorders. For example, personality and 

temperament research, neuroimaging, animal models of behavior, and genetic 

research recently have all converged in important new theories and findings 

regarding behavioral and biological aspects of mood and mood regulation. This 

work has important implications for such topics as the relationship between anxiety 
22

and depression, which has long been a source of controversy in both the clinical and 

experimental literatures. Further multidisciplinary research that builds on this 

emerging perspective might offer a more cohesive conceptualization of these and 

other mental disorders. 

B. FUNCTIONAL ABILITIES IN MENTAL ILLNESS

PRIORITY AREA 2. Understand how mental illnesses and their treatments affect 

the abilities of individuals to function in diverse settings and roles (e.g., carrying 

out personal, educational, family, and work responsibilities).

• Apply methods from basic behavioral science to the development of tools to 

assess functioning. 

• Use methods from basic behavioral science to understand how specific 

rehabilitation and other intervention techniques improve specific types of 

functioning. 

• Develop interventions that focus on improving functioning in addition to reducing 

clinical symptoms.

• Include the assessment of functioning as an outcome in intervention, services, 

and risk-factor research. 

a. Issue: A wide range of relationships and activities--including those at home, work, 

school, and in health care settings--can be limited by acute episodes of mental illness. 

In addition, chronic and recurrent episodes of severe illness or those that begin before 

adulthood may limit functioning even after primary symptoms have abated. The levels 

and domains of activity limitations may vary quite widely both within and across 

diagnostic categories and in individuals over time. Yet similar levels and types of 

disabilities can be seen in people with quite different diagnoses. For example, 

limitations in social functioning may occur in individuals with disorders as diverse as 

schizophrenia, bipolar disorder, major depression, and social phobia. These illnesses 

therefore can constrict an individual’s social-support network, resulting in fragile 

resources for coping with crises. 

Given these considerations, an assessment focused solely on diagnosis-related 

symptoms may not suffice for helping people who are struggling to cope with mental 

disorders. How consumers function at home, with friends, with health care providers, at 

work, and during leisure time may be equally important outcomes to address. For 

example, a young man with schizophrenia may find that although the new medications 

reduce symptoms of psychosis such as hallucinations, he still is having trouble going to 

a job interview or taking the driver's license test--two tasks essential to realize his wish 

for self-sufficiency and recovery. Another consumer with bipolar disorder, who now 

feels more in control of her mood fluctuations, might discover that some of her 
23

previously acquired skills--such as getting to work on time, negotiating public 

transportation, and managing money--need a great deal of improvement. A third person 

with depression, whose problems in functioning began in early adolescence and 

interfered with the development of social skills, may never have learned certain ageappropriate skills for initiating a personal relationship--an essential step toward fulfilling 

his dream of having friends and dating. 

Because impaired functioning creates a serious economic and social burden for our 

society, for people affected by the disorder and for their families, health care providers, 

payers, researchers, and policymakers need to pay increased attention to clients' levels 

of functioning--before, during, and after treatment. As the enormous functional toll 

exacted by mental illness gains increasing recognition (as illustrated by the recent 

international comparative data on disease disability and the Surgeon General's report 

on mental illness) (Murray & Lopez, 1996; U.S. Department of Health and Human 

Services, 1999), so too does the need for demonstrably effective ways to assess and 

improve consumers' abilities to carry out their responsibilities and manage residual or 

recurring symptoms of their illness. 

b. Research Avenues: Powerful research tools and theoretical perspectives are 

available in the behavioral sciences for examining issues related to functioning, 

including interpersonal interactions, social influence, emotion, learning, self-concept, 

and decision making. Research in the area of functioning needs to take advantage of 

these resources by linking to behavioral theory and methods. Some ongoing mental 

health research that focuses on or includes functioning is beginning to make those links, 

but most research to date does not. The opportunities for research on functioning 

described below suggest some ways in which behavioral science theory and methods 

could provide new tools for identifying and improving the functional abilities of people 

with mental illness.

• Measuring Functioning

Assessment of functioning has lagged considerably behind assessment of clinical 

symptoms in mental illness. The lack of standardized assessment and classification 

tools has hampered the ability of researchers and policymakers to assess accurately 

the form and frequency of functional impairments and to project future health care 

needs and costs. Recent efforts by the World Health Organization (WHO) and 

NIMH have led to the development of the WHO-DAS II, a generic measure of 

functioning that includes the domains of understanding and communicating, getting 

around, self-care, getting along with other people, life activities, and participating in 

society. The WHO-DAS II is now undergoing worldwide psychometric testing. Pilot 

studies are currently underway to determine its ability to predict service needs, 

health service use, and costs.

The WHO-DAS II is an exciting use of behavioral science with great promise for 

providing reliable and valid data to researchers and service providers. However, 

since it was designed to be used across many cultures and illnesses, instruments 
24

like this may not be as useful for informing everyday treatment and rehabilitation 

plans for a specific person. Basic behavioral science theory and methods can be 

used to devise instruments that will take into account issues that are more specific to 

an individual and his/her context and symptoms. These instruments also could 

evolve into sensitive person-specific measures of the subtle but important changes 

over time in an illness.

• Strengthening Rehabilitation Effectiveness and Functioning

Psychosocial rehabilitation generally is regarded as important to help people coping 

with mental disorders function in community settings. However, many rehabilitative 

interventions are not now grounded in research, and there is wide variation in how 

well these interventions help specific people with specific deficits. Researchers have 

documented numerous specific cognitive and psychophysiological deficits 

associated with mental disorders (e.g., in attention, information processing, and 

psychophysiological arousal). But there is little understanding of how those deficits 

are related to specific functional problems or how such problems may be addressed 

by rehabilitation approaches. Current research is seeking to make these links. 

However, much more work needs to be done to spell out completely the link 

between the neurological-cognitive deficits and the formulation of rehabilitation 

strategies that are specific for particular functional deficits.

• Understanding Illness Management and Recovery

Consumers in community settings need and want to be able to take care of 

themselves. To do so they must improve functioning that was diminished, 

compensate for functioning that was lost, and learn new skills that were never 

developed. Teaching and reinforcing those strategies is the goal of rehabilitation 

programs. Behavioral research examining how people perceive and regulate their 

own behavior promises to shed light on many of the central rehabilitation problems 

of mental disorders (Metcalfe & Shimamura, 1994). For example, researchers have 

shown that individuals' awareness of the nature of their deficit is one of the most 

predictive measures of whether they will be able to benefit from rehabilitation efforts 

and develop compensatory skills. However, people with certain clinical conditions 

do not understand that they cannot remember information, even about their own 

illness; others are unable to use that information when needed. These are called 

deficits of monitoring and of control. For instance, unlike people with other kinds of 

amnesia, those with Korsakoff's disease lack knowledge of what they will be able to 

remember. This impairment in monitoring may originate specifically from the frontal 

cortex. Neuropsychological and computational models have clarified how basic 

memory processes are related to the monitoring and control processes. They also 

point to a whole syndrome of deficits that should be related specifically to 

impairments in monitoring. 
25

Studies of individuals with impairments of control are few. People with such deficits 

have frontal lobe impairments and may have deficits related to the amygdala system 

as well. People with such deficits understand and can even fluently express what 

they should do, but cannot put that knowledge into practice. Clearly, this 

dissociation between monitoring and control processes has profound implications for 

daily functioning, as well as for our understanding of the basic architecture of human 

cognition. Much more detailed follow-up may clarify how these different components 

of cognition interact in different clinical and normative groups, and what intervention 

strategies might help people with such impairments. Deficits in monitoring and 

control may have important implications for functioning (in social relationships, work, 

at home and in school) and for the design of rehabilitation strategies.

• Enhancing Disorder Management and Functioning 

Managing the symptoms of severe mental illness so that an individual can remain 

engaged in the activities of life can be a daily challenge. Managing the illness 

typically requires taking medication that can have many discomforting side effects, 

including dry mouth, blurred vision, sedation, restlessness, sexual dysfunction, 

weight gain, and tardive dyskinesia (involuntary movements of the head and limbs). 

Understandably, many of those experiencing such side effects want to quit taking 

the medication, and some do. This can lead to an acute episode of illness.

Behavioral strategies can reduce medication side effects by teaching clients to 

identify symptoms, to monitor their behavior and emotions, and to develop more 

effective communication skills, all of which help them negotiate with health care 

providers regarding medication changes. A series of recent studies illustrates the 

effectiveness of behavioral training techniques (e.g., didactic instruction, modeling, 

response rehearsal, coaching, and contingent social reinforcement) in teaching what 

are known as collaborative medication management skills to people with 

schizophrenia who are likely to discontinue medication. As a result, behavioral skills 

training has been identified as an essential ingredient in a comprehensive 

biobehavioral approach to schizophrenia treatment. More refined assessments are 

needed of the functional impact of these interventions, in combination with other 

behavioral approaches for strengthening the illness-management skills of clients in 

community settings.

• Coping with the Social Environment

In addition to coping with the symptoms of their illness, many people with severe 

mental disorders struggle to establish or maintain successful relationships with 

family members, friends, and co-workers. The primary and most intense social 

contacts for many of these consumers are with family members. Behavioral 

research has guided the development and testing of family education and support 

groups that assist family members in understanding the illness and coping with dayto-day stresses. Behavioral family psychoeducation programs place considerable 

emphasis on improving communication and problem-solving skills; the programs are 
26

designed to enhance family members' ability to work together and minimize conflict. 

Most studies evaluating the effects of these family interventions have found that the 

psychoeducational programs for families produce dramatic reductions in the number 

and duration of acute episodes of illness among their ill relatives as well as improved 

health for family members. 

Recent studies also suggest there are behavioral methods for directly helping those 

with severe mental illnesses cope with life in the community. Two randomized 

controlled trials showed that over a 3-year period an individually tailored form of 

cognitive-behavioral therapy, in combination with antipsychotic medication, could 

significantly reduce relapse and improve social functioning among those consumers 

who were living with their families (Hogarty et al., 1997). Further research is needed 

to extend the breadth and duration of these effects to permit people with severe 

mental illness to live more productive and fulfilling lives. 

C. CONTEXTUAL INFLUENCES ON MENTAL ILLNESS AND ITS CARE

PRIORITY AREA 3. Understand how social or other environmental contexts 

influence the etiology and prevention of mental illness and the treatment and care 

of those suffering from mental disorders. Context includes interactions among 

factors at the individual, family, sociocultural, and service-system or 

organizational levels. 

a. Issue: To respond well to the mental health needs of Americans with mental 

illness--especially given our Nation's extensive cultural diversity--clinical practitioners, 

decisionmakers, and researchers need to understand how a variety of contextual 

factors affect the mental health service system and those who deliver and use (or do not 

use) its services. This point was made in a call to arms to psychiatry that applies 

equally well to the other mental health professions:

Psychiatry needs new ways of delivering culturally appropriate care to the 

disenfranchised and the destitute, for whom mainstream approaches are often too 

expensive, foreign, and centralized. As a profession, we also have much to learn from 

indigenous diagnosticians and therapists. Finally, psychosomatic, mind-brain, behavioral 

health, and psychopathologic investigations need to configure the social world in their 

paradigms of research if we are to understand better the sources and consequences of 

mental illness. Psychiatry can no more afford to be contextless than it can afford to be 

mindless or brainless (Emphasis added) (Lewis-Fernandez & Kleinman, 1995). 

Mental disorders arise and are treated in complex biological, sociocultural, and 

economic settings. People with these disorders differ in their individual characteristics 

and in their manifestations of and responses to illness depending on the community and 

cultural environments in which they live. The organizations that provide mental health 

and rehabilitative care operate with a range of values, styles, goals, and financial 

restrictions. Their capacity to address the individual needs of those with mental illness 

may be affected by their social, economic, and legal environments. All these contextual 

factors--individual, sociocultural, and organizational--have main and interactive effects 
27

on risks for illness, course of illness, help seeking, and responses to interventions. 

These effects, individually and in combination, need to be identified and assessed to aid 

in designing and/or developing interventions appropriate to the needs and 

circumstances of specific individuals or groups suffering from mental disorders.

Contextual factors are particularly salient in research on disparities in the receipt and 

quality of mental health care. Excellent mental health treatment should be available to 

all Americans, but there are still significant socioeconomic, geographic, and ethnic 

disparities in the seeking, use, and provision of care, as well as treatment outcomes. A 

significant issue in this regard, which needs a contextual research approach, is 

diagnosis. Evidence shows that the diagnosis one receives can be strongly influenced 

by the racial group to which one belongs. Also relevant is research evidence that 

identification of certain mental health problems--whether defined by Western mental 

health professionals (e.g., anorexia) or through folk and cultural traditions (e.g., ataques 

de nervios, see (b) below)--are highly dependent on the sociocultural backgrounds of 

the clinician and the consumer. These and other findings indicate the necessity for 

more methodologically sophisticated and behaviorally informed research on diagnosis 

and the diagnostic process. 

Areas within mental health services research, such as research on help seeking, 

treatment, and outcomes, also need a contextual perspective. Evidence shows that 

those who are not part of the mainstream culture are more likely to seek services and 

respond best if those services are provided in an environment that is geographically 

accessible and socially and culturally comfortable for them and respectful of them. To 

alleviate disparities in help seeking, treatment, and outcomes, consideration of 

sociocultural and other contextual factors is essential. 

The basic behavioral and social sciences have extensive literatures that are gold mines 

for mental health research conducted from a contextual perspective. They focus on the 

very social, cultural, psychological, and market factors influencing behavior that are 

critical for a contextual perspective. Theory, methods, and empirical findings in these 

literatures can aid understanding of issues such as:

• Individual: How social and cultural influences at the individual level--such as 

developmental history, styles of expressing emotion, levels of motivation, 

personality, beliefs, values, preferences, needs, and goals--affect risk for mental 

illness and inform the development, design, and targeting of new interventions, 

and how such characteristics affect behavioral responses to prevention and 

treatment.

• Sociocultural: How ethnicity, culture, language, socioeconomic class, family 

and social networks, and neighborhood or community affect risk, diagnosis, 

prevention, and treatment of mental illness.
28

• Organizational: How policies, incentive structures, and cultures at all levels of 

health/mental health organizations and institutions affect the behavior of those 

providing care and of those receiving it, as well as the outcomes of care.

There has been some research collaboration among basic researchers, services 

researchers, and service providers. But much more intensive efforts are needed to 

ensure that basic behavioral theory, methods, and empirical findings relevant to 

contextual issues inform research on diagnosis, engagement, and care of those with 

mental disorders. The following research examples suggest some of the exciting 

findings that have emerged from beginning steps taken in this direction. 

b. Research Avenues: 

• Diagnosing Symptoms and Functioning Across Cultures and Subcultures

New tools and approaches are critical for understanding a variety of difficult 

treatment and service issues. Anthropological and cross-cultural research studies 

have shown that the expression of emotion can vary widely across cultures, as can 

mental illness symptoms, their meanings, and the categories of mental disorders. A 

cross-cultural research program on diagnosis should examine how these differences 

affect individuals' experience and reporting of symptoms; how the expression of 

emotion affects diagnosis; how the language of interview affects the assessment of 

individuals in their first and second languages; and how social distance due to 

ethnicity, class, and gender affects the diagnostic process.

The benefits of cross-cultural approaches to diagnosis are illustrated by research on 

ataques de nervios (attacks of nerves) among some Latino populations in the United 

States (Guarnaccia & Rogler, 1999). This research has determined that this culturespecific illness refers to distinct patterns of loss of emotional control and that the 

type of loss of control (fear vs. anger) is related to specific mental disorders (panic

vs. mood disorder). This research has also suggested that these clusters may prove 

to be useful markers for detecting mood and anxiety disorders among Latinos. 

• Developing Measures and Interventions through Ethnography

Some research questions regarding the etiology and course of mental disorders 

require an ethnographic approach. Ethnographic and other qualitative methods, 

which have a long history in anthropology, describe illness and suffering in relation 

to the sociocultural contexts in which they occur. This requires that researchers 

consider the nature of mental disorders, and necessarily involves issues of 

“meaning” and “value” that contribute to people's perceptions of themselves and 

their world. This approach has proved quite useful in two areas of applied research: 

measurement development and intervention development.
29

• Measurement Development

When doing research in community settings, investigators need to account for 

variations in how care is delivered. One concept that has been assumed to 

be critical is “continuity of care.” However, researchers have typically 

approached this concept through ad hoc measurement of related constructs, 

such as number of visits or presence of a particular type of service. This 

limited conceptualization recently has been expanded. An ongoing 

ethnographic study has sought to identify the elements of continuity of care by 

documenting the interpersonal processes of giving and receiving care (Ware 

et al., 1999). Through careful interviews with clients and clinicians, the 

investigators have identified six mechanisms of continuity, which they term 

pinch hitting, trouble shooting, smoothing transitions, creating flexibility, 

speeding the system up, and contextualizing (or helping the client perceive a 

discouraging situation less negatively). Through this ethnographic work, a 

scale has been constructed that is being used currently in psychometric 

testing in ethnically diverse populations.

• Intervention Development

Caregivers working with people with severe mental illness in the community 

need to encourage health-promoting behavior in all aspects of life. This is 

especially important to prevent additional illness and because having comorbid substance abuse and/or medical disorders complicates and 

exacerbates severe mental illness. Such efforts depend, in part, on 

understanding the perspective of the specific consumer population. Research 

built on an awareness of cultural contexts can aid in developing interventions 

that give consumers well-grounded, comprehensible information, respond to 

their personal concerns and viewpoints, and give them the skills needed to 

refrain from behavior that can compromise their physical or mental health.

Recent research has demonstrated the potentially life-saving power of 

culturally sensitive preventive interventions for individuals with severe mental 

illness (Susser et al., 1998). Because an elevated rate of HIV infection has 

been found in this population, developing an effective HIV preventive 

intervention for people with severe mental illness--especially those who are 

homeless--has been a high priority for NIMH. To encourage safer sex among 

homeless minority men with severe mental illness, a research team recently 

conducted a randomized clinical trial of an ethnographically based socialskills training curriculum built around the activities and the language of the 

men's daily lives in their shelter. The cultural relevance of the intervention 

made it meaningful and interesting to the men and held their attention despite 

the cognitive impairments produced by their illness. 

During the initial 6-month follow-up, the experimental group's mean score on 

a sexual risk index was three times lower the control group's; it was two times 
30

lower during the remainder of the 18-month follow-up. This intervention 

successfully reduced sexual risk behaviors of homeless men with mental 

illness; although the effect diminished over 18 months, it did not disappear. 

Further behavioral research of this type, which combines ethnographic 

sensitivity with social-skills training, is essential to enhance other health- and 

mental health-promoting behavior in people with severe mental illness in a 

variety of living environments, communities, and cultural contexts. 

• Framing Messages in Context for Health 

A developing body of behavioral science research promises new insights and 

approaches to aid in encouraging consumers to seek, remain in, and adhere to 

treatment, as well as motivating providers to offer appropriate diagnoses, 

treatments, counseling, or referrals. The rich array of techniques used to change 

behavior--whether of consumers or providers--includes tailoring messages so they 

are understood and accepted by the intended target groups. Research on "framing" 

focuses on the behavioral impact of the way in which messages are presented. To 

“frame” a message so that it will be effective, the framer must directly address 

individual and sociocultural contexts of the people whose behavior he or she seeks 

to change.

 

Message framing has received considerable study in health care and public health 

as researchers seek the best ways to reach consumers with health messages (see 

box below, "Taking a Chance on Health: The Impact of Message Framing"). To 

date, however, there has been relatively little framing research in the mental health 

arena--a research gap that begs to be bridged.

 
31

Taking a Chance on Health: The Impact of Message Framing

A crucial aspect of health education is knowing how to frame messages effectively to encourage 

behavior change. For example, in trying to encourage women to have mammograms, is it better to 

emphasize the benefits of doing it (“gain-framed” messages, e.g., "Obtaining a mammogram allows 

tumors to be detected early; this maximizes your treatment options") or the costs or risks of not doing 

it (“loss-framed” messages, e.g., "If you do not obtain a mammogram, tumors cannot be detected 

early; this minimizes your treatment options")? 

One of the first examples of translational research based on basic decision science principles was an 

attempt to persuade women to use monthly breast self-examination (BSE). Women were asked to 

read one of two pamphlets describing BSE. The first emphasized its potential benefits (gain-framed 

message) and the second the potential costs of not doing it (loss-framed message). The loss-framed 

pamphlet was more effective in promoting BSE than the gain-framed one. The particular 

effectiveness of loss-framed messages in encouraging BSE makes sense in light of laboratory work 

on framing and risk-taking. BSE is perceived as an uncertain or risky behavior; it is not done to 

prevent cancer; rather it is performed in order to detect it. Each time a woman performs BSE, she 

runs the risk of finding a lump or another abnormality. 

An additional decade of research revealed that the influence of message framing on health behavior 

depends on the type of behavior being promoted (Rothman & Salovey, 1997). Loss-framed 

messages were effective in promoting mammography and BSE, early-detection behaviors. But gainframed messages were effective in promoting the use of infant car restraints, exercise, smoking 

cessation, and sunscreen--all prevention behaviors. The uncertainty associated with detection 

behaviors means that loss-framed messages should be more persuasive in promoting them. 

However, prevention behaviors are not perceived as uncertain or risky at all; they are performed to 

deter the onset or occurrence of a health problem, and gain-framed messages are more effective in 

encouraging them. 

The correct match between a message frame (gain or loss) and the required health behavior 

(prevention or detection) especially motivates behavior change. A return to the laboratory allowed a 

more precise test of this framing by behavior-type hypothesis using hypothetical diseases, as well as 

taking a given health behavior--using a daily mouth rinse--and describing its function as prevention or 

early detection. This line of research began in the cognitive psychology laboratory then became 

"translational" in the sense that it was used in large-scale, field-based experiments designed to 

promote health behaviors in community-based interventions. Future research in this area needs to 

test whether much more targeted messages, which take into account contextual variables such as 

culture, status, and family illness history, will improve motivation to change behavior.

• Understanding the Impact of Organizational Context and Climate 

Integrating the theory, methods, and knowledge base of behavioral science into 

services research can lead to new types of studies and new insights into critical 

service system issues. One such study (Glisson & Hemmelgarn, 1998) was 

designed to determine whether efforts to increase coordination of children's public 

service agencies improved service quality and children's outcomes, as many 

researchers, providers, and policymakers expected they would. However, based on 

the literature in organizational theory, the investigators also assessed how other 
32

characteristics of the organizations--which included their overall culture and climate--

affected the same outcomes. 

The research team collected both qualitative and quantitative data over a 3-year 

period describing the services provided to children in one State. They found that the 

tested intervention--increasing coordination between organizations--had a negative 

effect on service quality and no effect on children's outcomes. In contrast, a positive 

organizational climate (including low conflict, cooperation, role clarity, and 

personalization) was the primary predictor of positive service outcomes (the 

children's improved psychosocial functioning) and a significant predictor of service 

quality. These findings--if supported by other studies--have immediate policy 

relevance because they suggest an approach to improving children's services more 

promising than traditional efforts focused only on organizational coordination. The 

lesson from this research is to focus on creating positive climates within 

organizations rather than on simply increasing coordination among them. 

D. CONCLUDING COMMENTS

This chapter merely hints at the wealth of opportunities for translational research 

embedded within the Workgroup's three priority areas. Many more are suggested in the 

box below, “Further Research Avenues.” However, turning research promise into 

tangible benefits for people with mental illness and for the science of human behavior 

requires well-planned, well-supported, and sustained effort by NIMH over many years. 

A framework for that effort is presented in the next chapter.
33

Further Research Avenues

Behavior science theory and findings offer rigorous directions for exploring many other 

concerns raised by individuals with mental disorders, their families, and their providers. 

The following behavioral science research opportunities round out the examples in this 

chapter. 

• Stigma: Research has revealed the processes underlying stereotyping of individuals 

from ethnic and gender groups, as well as the functional costs that stem from fear of 

such stereotyping. Can these principles assist in constructing a program to 

destigmatize mental illness for the general public, the courts, the police, or 

emergency room workers?

• Eating and Smoking Regulation: For patients with severe mental disorders, weight 

gain is one of the troublesome side effects of medication. Can techniques for 

modifying eating behavior to improve weight loss in the general population be 

successfully applied to this specific group? Smoking cessation has been found to be 

particularly difficult for people with schizophrenia. Can behaviorally developed and 

evaluated smoking cessation programs be tailored and tested for effectiveness 

among these and other individuals with mental disorders?

• Consumer Education: Treatment research findings indicate that patients who 

receive educational counseling about mental illness or other illnesses can more 

closely follow their treatment plan. Are there cost-effective methods for providing this 

education through videotape or consumer educators that would enhance treatment 

adherence?

• Burden of Care: Behavioral research with families of Alzheimer’s patients 

demonstrates growing sophistication in quantifying the burden of care for family 

members and in developing methods to ease this burden. Further research is 

exploring how consumers view the help received from family members. Can testing 

these findings--and the underlying models of social support, altruism, and selfesteem--for generalizability to burdens associated with mental illness provide 

important information for consumers and their families?

• Decision Making: Basic research is beginning to reveal the processes that guide 

and sometimes misdirect decision making by individuals and groups in the 

laboratory. Further research promises to extend these insights to clinical contexts. 

Can these models be translated into decision rules that consumers and their 

providers can and want to use in developing effective treatment plans? Topics for 

investigation could include the cognitive processes underlying diagnosis and 

planning or evaluation of treatment, as well as clients' seeking of and adherence to 

treatment. A related direction for future work is the design and use of artificialintelligence technology to assist in clinicians' decision making.
34

IV. FROM KNOWLEDGE TO ACTION:

THE NIMH LEADERSHIP ROLE

The three priority research areas discussed in Chapter III (Basic Behavioral Processes 

in Mental Illness; Functional Abilities in Mental Illness; and Contextual Influences on 

Mental Illness and Its Care) are so central to the core mission of NIMH that it may seem 

puzzling that they needed to be highlighted by the Workgroup for special 

encouragement. They pose many interesting research questions that might be 

expected to attract and excite a substantial number of behavioral scientists 

spontaneously. However, the representation of such research in the current NIMH 

portfolio is limited, suggesting that these are difficult areas to develop. (Indeed, NIMH 

staff are also working on strengthening the translational portfolio built on basic 

neuroscience and genetic science.) At present too few researchers are attempting to 

bridge across basic, clinical, and services research, and not enough are working with 

colleagues in related allied disciplines to move research advances out of the laboratory 

and into clinical care and policymaking.

NIMH can and must play a catalytic role in initiating and sustaining activity in the priority 

areas for translational research described in the preceding chapter. Because specific 

research avenues within these areas are at different stages of development, they will 

require different strategies and timetables for moving forward. For some avenues, the 

first step should be exploratory meetings blending basic, clinical, and services 

researchers with consumers, family members, providers or policymakers; for those 

topics that are better developed, issuing targeted RFAs, PAs, or contracts may be a 

relatively early step. Still others may first require changes in training, the creation of 

multidisciplinary research centers, or some combination of approaches. But all priority 

areas will benefit from a systematic, phased approach to development that assesses 

their current status and needs, their potential contributions to clinical care, and the steps 

required to realize those contributions. To be successful in these efforts, NIMH, of 

course, must embody in its administration of translational research the same spirit of 

multidisciplinary collaboration and coordination that it fosters in the research community. 

This chapter describes a comprehensive NIMH approach to building, sustaining, and 

applying systematically the behavioral knowledge needed to improve critical aspects of 

mental health care. Although the examples and recommendations are focused 

specifically on facilitating translation of behavioral science, many are applicable to the 

generic problem of moving knowledge gained from any basic science into clinical and 

services research and ultimately into clinical practice and service systems. 

A. BUILDING THE FIELD: FIRST STEPS

NIMH stimulates outstanding mental health research through a blend of scientific 

leadership and efficient research administration. As the leading supporter of basic and 

clinical behavioral science, as well as treatment research and services research related 
35

to mental illnesses, NIMH is strongly positioned to build a successful and enduring 

program of translational behavioral research. However, it needs to make efficient and 

effective use of its considerable resources and roles, which include, in addition to being 

a catalyst for new research directions, being an integrator, convener, and influential 

mental health/public health advocate. 

Establishing a viable program of translational behavioral science research at NIMH will 

require special effort and incentives to overcome the extensive structural, financial, and 

attitudinal barriers discussed in Chapter II. NIMH needs to address effectively and 

comprehensively a host of very practical questions. These include:

• How can basic researchers at various points in their careers be attracted to 

pursue unconventional and even risky avenues of needed translational research?

• How can they be trained or partnered with others to conduct such research, and 

who will train them?

• How can excellent behavioral, clinical, and services researchers be encouraged 

to collaborate in translational research projects? 

• How can reviewers with expertise in specific areas be briefed to recognize the 

best translational research?

• How can translational researchers be encouraged to consult and collaborate with 

consumers and community representatives in the design and development of 

research? 

• How can such researchers find and exchange information readily with one 

another, with prospective collaborators in other disciplines, and with end-users of 

their findings--consumers, policymakers, practitioners, and payers? 

These issues are addressed in the remaining sections of this chapter.

The Institute also must address a critical research policy question: Which, if any, areas 

of translational research should it choose to stimulate immediately, and how should it 

phase the overall development of the research program? The Workgroup has identified 

three priority areas that represent first focal points for the emergent research program. 

However, long-term efforts are required to assess the changing state of knowledge and 

need in these and other research areas, determine the readiness of specific findings 

and theories for development toward clinical goals, and design a phased plan of action. 

It is essential to capitalize immediately on the attention and interest generated by 

NAMHC reports such as this to educate the field and stimulate its interest in 

participating in translational research. To jump-start the field and to alert the research 

community to the immense opportunities for knowledge advancement and mental health 

service presented by behavioral translational research, NIMH must make a highly 

visible commitment to developing the field. 
36

Accordingly, a number of steps should be initiated immediately:

• Issuing RFAs for Translational Research in Priority Areas of Study

 

An RFA is a one-time call for research in a specific area. Its goals and criteria are 

clearly stated for researchers and for reviewers alike. Because it offers a funding 

set-aside, it is perceived by the research community as representing a priority area 

of research. NIMH is permitted to tailor review criteria for RFAs, since the reviews 

are held at the Institute. The opportunity for review through NIMH rather than 

through the NIH CSR, which oversees peer review of most investigator-initiated 

applications in behavioral science, has other advantages. The NIMH review 

structure can readily adopt some of the recommendations proposed in this chapter 

that would be unwieldy for CSR to undertake. 

Having identified three priority areas of research: (1) Basic Behavioral Processes in 

Mental Illness; (2) Functional Abilities in Mental Illness; and (3) Contextual 

Influences on Mental Illness and Its Care), the Workgroup recommends that these 

be the foci for an initial series of RFAs, beginning with Priority Area 1. Other RFAs 

to follow include one focusing on interventions informed by theories of basic 

processes in mental disorders. It is important from the outset to highlight the need to 

develop interventions, both as a way to move behavioral theory into clinical practice 

and as a way to test behavioral theory in clinical populations. To aid in assessing 

basic behavioral processes, another prospective RFA or request for proposals 

(RFP)10 should call for the development of psychometrically sound tools for 

determining diagnosis and level of impairment--based on contemporary 

measurement theory--for use by practitioners; such practical assessment tools are 

urgently needed in clinical settings. 

• Creating a Systematic Implementation and Evaluation Plan

Although these RFAs signal important new research opportunities, they are only the 

beginning of a long-term process of inquiry, assessment, and program development. 

The Institute needs to create a systematic implementation plan for the long-term 

development of research in the three priority research areas--one with clear goals 

that permit later assessment of the program's success. 

Recommended steps include establishing a detailed baseline "snapshot" of the 

current NIMH translational research portfolio in the three priority areas. (The 

definition of translational research presented in the Executive Summary may provide 

a basis for developing an operational definition for this task.) This baseline would 

aid in current program development and would serve as one basis for an 

evaluation--perhaps a decade hence--of the success of the Institute's efforts in 

fostering translational behavioral science research. 

 

10 RFP is a call for contract activity. 
37

• Additional Mechanisms to Stimulate Research

• Other Research Announcements

The Workgroup strongly encourages NIMH staff to use every mechanism at 

their disposal to signal the Institute's strong interest in translational research 

and encourage the development of this field. This means, in addition to 

issuing the RFAs described above, following them up with standing 

announcements to the field--e.g., PAs--to emphasize the Institute's ongoing 

commitment to these research areas.

In light of the broad recommendations of this report, the Institute also should 

consider revising and/or reissuing existing translational research 

announcements germane to translational behavioral research (e.g., in the 

areas of dissemination research, human subject protections, and services 

research). It is important to note, however, that after the fairly low response 

to these efforts, future attempts in these areas must first identify important 

and attractive research issues as RFA/PA topics, and communicate these 

research opportunities effectively to the field.

As with other announcements noted above, PAs could follow RFAs to signal 

the Institute’s ongoing commitment to these research areas. Mechanisms to 

alert and educate the field and stimulate research include workshops, 

research reviews, presentations to scientific and professional meetings, and 

journal and newsletter articles. 

• Workshops and Conferences

The Institute can stimulate translational research through two broad types of 

meetings: (a) multidisciplinary meetings that bring together experts in basic 

behavioral research with their counterparts in clinical research and services 

research; and (b) meetings of behavioral researchers with consumers and 

experts from allied areas. Although their format and content will differ 

considerably, both types of meetings should focus on identifying specific 

areas of promise for translational research within the priority areas. In 

addition to their contributions to information exchange and research agendasetting, such meetings and follow-up mechanisms should be structured to 

encourage subsequent collaborations among the participants. 

Workshops and conferences, particularly when designed to encourage 

repeated contacts among carefully chosen participants, represent an 

important way to stimulate research and encourage groups to exchange 

information and perspectives. With the right mix of people and resources the 

Institute can create a venue where guild, patent, publication, profit, and 

advocacy issues can be put aside to consider both science and public health, 

or at least to consider how these issues can serve the public's health. 
38

Experience in both the cancer and AIDS research arenas has underscored 

the importance of including in the research development process key 

stakeholders, including representatives from consumer and family groups, 

health-care delivery groups, practitioners, third-party payers, and employers. 

Broad inclusion should be the rule, not the exception. NIMH should add to its 

meetings representatives from basic science and clinical science, as well as 

allied fields with behavior-change expertise beyond the traditional mental 

health or academic sciences. The Institute also should provide participation 

opportunities for more junior researchers. Finally, other public and private 

funders and end-users of information should be routinely invited so that other 

sponsors and potential users of research knowledge can participate in 

shaping research questions. 

• Research Syntheses 

NIMH’s leadership role is predicated on knowing and advancing the current 

state of research. Staying abreast requires talented staff and a willingness to 

foster many types of research synthesis. This synthesis effort is a 

prerequisite for implementing many of the recommendations at the end of this 

chapter. NIMH needs to generate broad reviews that take stock of what is 

known and what is needed in all research areas relevant to behavioral 

translational research. The value of the synthesis effort is contingent upon 

accessing and systematically analyzing all research that meets certain 

standards (regardless of publication status or success). Since many studies 

are too small in and of themselves to detect whether a particular intervention 

worked, meta-analysis can provide one powerful tool for merging data from 

multiple studies. 

• Fostering Communication Related to Behavioral Translational Research

One of the central barriers to translational research is a lack of communication--

across disciplines, across levels of inquiry, across departments and schools, 

sometimes across NIMH organizational lines, and among researchers, practitioners, 

and consumers. It is important to consider from the outset ways to break down 

communication barriers among groups whose collaboration is essential to 

transforming basic research into meaningful clinical advances. The meetings 

mentioned above are one important vehicle. The NIMH Web site offers another 

important means of rapid research dissemination to a variety of potential 

professional and lay audiences. NIMH also needs to consider ways to make key 

research findings and research opportunities accessible to those who need to know 

about them--whether they be practitioners, policymakers, consumers, or researchers 

outside the originating discipline. One of the first steps taken by NIMH staff should 

be to prepare articles on research opportunities in translational research for 

publication in scientific journals that reach a broad audience of basic behavioral, 

clinical, and services researchers. 
39

• Enhancing NIMH Staff Resources through Consultants 

NIMH staff work is essential to develop outstanding translational research and to 

review, award, and monitor research grants and contracts in this emerging research 

area. These vital roles ensure the Institute's ability to encourage, select, and

sponsor important research from the many applications submitted for funding. 

Research administration requires a blend of system know-how and a keen 

understanding of substantive issues. Initiating time-limited NIMH appointments for 

outstanding translational researchers who serve as consultants in all three research 

divisions that fund basic behavioral research can invigorate NIMH programs and 

program staff while offering invaluable experience to the consultants themselves. 

Roles for such visiting scientists could include conducting staff training workshops 

and seminars as well as special workshops at scientific meetings for potential 

grantees. 

B. OPTIMIZING THE PEER-REVIEW PROCESS

Peer review engages the best and the brightest researchers to consider the merits and 

weaknesses of their peers' applications for funding. This process must be finely tuned 

to the growing needs in the field and in the communities, such as the need for 

translational research. Clinical and basic researchers as well as practitioners 

interviewed for this report expressed concern that peer-review groups undervalue 

translational research.

Peer reviewers, who are essential advisors to the Institute, are placed in a difficult role. 

They are asked to evaluate and discuss the scientific merit of applications, but usually 

without the opportunity to review an Institute’s portfolio or its objectives for research. 

This information should be made more readily available to reviewers, both at NIMH and 

at the NIH CSR. NIMH should encourage a new orientation process that gives 

reviewers excellent syntheses of research areas, addresses the technical and review 

issues in new research priority areas, and provides information on the current portfolio 

and program initiatives, and the programmatic objectives for moving the portfolio 

forward. In addition, periodic "booster shots" (e.g., at the start of review meetings) 

would be helpful. 

A critical issue for translational research that can potentially pose problems for review is 

its boundary-breaking integration of disciplines and research perspectives. Thus, in 

addition to preparing reviewers adequately for their roles, it is essential to ensure that 

any group reviewing such research has the requisite mixture of expertise in basic, 

clinical, services, and other relevant research areas. 

To encourage and expedite pathbreaking research, NIMH should adopt a formal 

method for considering rapid revision of cutting-edge translational research when the 

review group has indicated specific but remediable problems that can be resolved to the 

satisfaction of NIMH staff and Council. These procedures should be made known to 
40

applicants. In addition, NIMH should revise and expand the focus of the B/START 

(Behavioral Science Track Award for Rapid Transition) and RAPID (Rapid Assessment 

Post-Impact of Disaster) announcements to expedite the submission, review, and 

funding of initial pilot efforts for translational research in practice settings. 

C. FOSTERING COLLABORATIONS

Overcoming the barriers to translational research requires both effective communication 

and incentives to prepare and attract potential researchers and research participants. 

As recent NIMH experience illustrates, simply issuing PAs to the field is insufficient to 

stimulate translational research. The Institute needs to exploit its ability to promote 

innovation and collaboration through incentives that increase the speed and likelihood 

of getting funding for innovative ideas in the behavioral translational research arena, 

and that foster collaboration of behavioral scientists with clinical peers, methodological 

experts, providers of care, and consumers. 

• Providing Incentives for New Collaborations

Meetings and reviews provide one avenue for sensitizing and alerting the field to 

new research opportunities and fostering collaboration and exchange. Further, 

although the NIMH research portfolio is largely driven by investigator-initiated 

research, many funding mechanisms in addition to RFAs are available or can be 

created to shape and focus aspects of that portfolio in desired directions. To 

increase interdisciplinary contributions to translational research, for example, NIMH 

needs to exploit funding mechanisms that mandate the collaboration of basic 

science, clinical, treatment, and services research (e.g., the model of the National 

Cancer Institute’s (NCI’s) clinical research centers). Collaboration requirements 

should be addressed in mechanisms aimed at junior and senior investigators, as 

well as in pre- and postdoctoral training and fellowship programs. 

NIMH also can invite current basic behavioral scientist grantees to apply for 

supplements to include clinical populations as participants in their research grants in 

ways that address the translational research agenda. Similarly, current clinical and 

services research grantees should be invited to apply for supplements to include 

research on basic behavioral processes, functioning, and/or context in their research 

grants. These supplements could be competitive or administrative, undergoing an 

expedited, in-house review. The Institute also should offer supplements for the 

addition of basic behavioral scientists to ongoing clinical research at academic, 

provider, health plan, state, and local settings. 

• Forming and Supporting New Alliances for Research

Conducting translational research will require new alliances and methods of 

developing and supporting such partnerships. NIMH should solidify its existing 

working relationships with other agencies/organizations, such as the Agency for 
41

Healthcare Research and Quality (formerly the Agency for Health Care Policy and 

Research), the Substance Abuse and Mental Health Services Administration, the 

Centers for Disease Control and Prevention, and private businesses or nonprofits. It 

also needs to build partnerships through mechanisms linking health systems, 

services researchers, state mental health agencies, and academic research centers, 

including the Veterans Administration or the HMO Research Network. These 

collaborations open windows to research settings, populations, and opportunities for 

behavioral science research that extend well beyond those traditionally used in 

laboratory-based basic behavioral science research.

For researchers who wish to pursue research questions in these new practice 

settings, the lengthy grant-acquisition process can pose problems, as noted in the 

NAMHC 1999 Bridging Science and Service report (NAMHC Clinical Treatment and 

Services Research Workgroup, 1999). The time frame is often too short to establish 

the kinds of relationships needed to encourage practice settings to adopt research 

innovations. NIMH needs to explore ways to provide additional flexibility to: (1) 

permit planning grants for research development in practice settings; (2) pay for the 

time and resources that practice settings devote to the research venture; and 

(3) allow the private businesses, state and local governments, and advocacy groups 

to identify and articulate their own research questions and recruit researchers to 

answer them. 

Community-generated research provides an opportunity to enhance the utility of 

research findings by changing the relationship between the researcher and the 

community. Community research programs began in the Netherlands and are now 

quite common throughout northern Europe and are growing in the United States as 

well. They typically involve partnerships with universities but also can involve 

researchers from any base to address problems of community concern. While 

environmental issues have been a common focus of these programs, community 

programs are likely to find translational mental health research of central importance 

given evidence about the large burden of illness imposed by mental disorders. 

Government support for such efforts could have many positive outcomes for public 

understanding of science, development of research skills among young people, and 

increased knowledge about many fields, including mental health. The clinical trials 

network initiated by the National Institute on Drug Abuse provides another example 

NIMH might consider as a potential model for community-based research 

addressing mental health issues. 

• Creating Multidisciplinary Settings for Translational Research 

In many developing areas of research, multidisciplinary, problem-focused research 

centers provide an important mechanism for concentrating scarce resources and 

bootstrapping a field. In addition, they are often excellent sites for training a new 

generation of researchers adept at multidisciplinary work. NIMH first should build on 

its existing research centers to provide opportunities for new translational 
42

research, speed the translation of findings, and encourage interplay across basic, 

clinical, and services research. 

The Workgroup favors initially offering existing research centers competitive 

supplements (e.g., for access to consumers, laboratory equipment, staff, clinical 

trials) to emphasize the integration of behavioral science in basic, clinical, and 

services research, as well as greater interaction at the interface between behavioral 

and biological science. The Institute subsequently may choose to create selectively 

one or more new translational research centers--with specified goals and finite life 

spans. Such centers should be organized around state-of-the-art behavioral science 

approaches to clinical problems, should include both behavioral and clinical 

scientists, and should demonstrate access to clinical populations or service settings.

D. CREATING TOMORROW'S RESEARCHERS

In an era of increasing specialization, there are few researchers who can see a body of 

work through from theory development to clinical implementation and even 

"manualization" and dissemination of the theory-based intervention. Nonetheless, it is 

possible, and even necessary, for multiple individuals to mine a body of basic 

behavioral research for its potential contributions to clinical practice and to ensure that 

appropriate teams of experts move promising work forward to the next stages of 

development. Many areas of basic behavioral research offer tantalizing possibilities for 

improving the lives of people with mental illness by contributing to new interventions, 

identifying the active ingredients of interventions, and using interventions to test basic 

behavioral models. However, turning these research possibilities into realities requires 

attracting and training a cadre of researchers who have the special skills and 

interdisciplinary orientation needed for translational research. 

Investing in the training of young scientists to conceptualize translational research and 

work in multidisciplinary teams is likely to have the greatest long-term return of any 

investment in this area. If trainees are acculturated in doing this kind of translational 

work early in their careers, they are likely to continue to do it and to train their students 

to do this kind of work as well. 

• Training Support

Major changes are occurring in the funding structure of universities, medical schools, 

and research institutes that have significant ramifications for research training. 

Because the Federal mechanisms for funding training, especially the National 

Research Service Award (NRSA) mechanisms, have certain mandated limitations 

(e.g., tuition reimbursement and other expenses), NIH should re-examine some of its 

policies in light of current and future needs of translational research training. Of 

particular importance, current levels of funding for training need to be increased 

dramatically to accommodate these changes. Accordingly, budget policies need to 

be altered to allow: 
43

• Costs for training-related expenses to include support for administrative staff 

and training faculty. Not allowing these costs (see below) makes it virtually 

impossible for many particularly relevant training settings to apply for training 

grants. These include research institutes outside of university settings such 

as many clinical service centers settings (e.g., health plan research centers 

and medical health research and service centers). These are precisely the 

kinds of sites that would be most useful to cultivate translational research 

training because of their ready access to patient populations and to clinical 

and services researchers. It should be noted, however, that current NRSA 

policies do allow requests for additional training-related expenses in 

circumstances where they can be strongly justified.

• Payment to be based on the actual costs of training rather than the current 

formula approach, which does not cover staff costs and creates a disincentive 

for high-tuition institutions that rely on faculty self-generating salaries to apply 

for training funds. This lack of support for covering staff time is particularly 

problematic for translational research, which requires the interaction of such 

individuals to stimulate excellent training. 

• Small-scale funding of pilot and small studies in targeted areas (e.g., 

translational research). In many cases, translational research cannot be done 

with volunteer undergraduate subjects or may require additional subject 

samples that complement a mentor's project. Thus trainees, particularly at 

the postdoctoral levels, should be allowed to request additional funds for 

subject payment, clinician oversight, and other necessary research expenses. 

• Extra resources in funding translational training grants, fellowships, research 

education grants, and career awards (such as extra training positions or 

preferential funding) to outstanding programs and investigators that are wellpositioned to bridge basic and applied research in mental health. This 

enhancement would explicitly acknowledge that establishing, conducting, and 

maintaining mental health translational research and research training is 

difficult and requires more resources than research that is less 

multidisciplinary and multidepartmental or even multi-institutional. 

• Fostering Training to Bridge Multiple Research Areas

Promoting significant progress in behavioral translational research requires training 

researchers at all career levels (pre- and postdoctoral students as well as 

established researchers/faculty) to conduct studies that bridge across basic, clinical, 

and services research. NIMH can contribute appreciably to this new research 

climate by fostering individual fellowship programs and career awards that require 

two mentors, one in the basic arena and one in the clinical/services arena. In 

addition, NIMH needs to support research education programs that provide 

opportunities for basic behavioral and social science students to interact with clinical 

students, exchanging basic and clinical course work and expertise. Such programs 
44

should include courses on new state-of-the-art behavioral science methods and 

clinical nosology, and ideally should involve faculty exemplars who combine basic 

research expertise with expertise in clinical and/or policy issues. 

To encourage established researchers to extend their domains of investigation and 

collaboration, NIMH should support research education programs that provide shortterm training to enable basic researchers to learn about clinical and services 

research, and clinical and services researchers to learn about basic research. If 

feasible and appropriate, this might include a rotation at the NIMH intramural 

research program.

E. REFINING QUESTIONS AND USING APPROPRIATE METHODS11

How adequate are current methods for addressing translational research questions? 

NIMH needs to answer this question to provide a basis for integrating and adapting 

existing methodological tools more effectively, for developing new tools as needed, and 

for identifying effective ways to disseminate them. Historically, NIMH has very actively 

and effectively furthered the methodological basis for mental health research. But to 

keep pace with its new emphasis on translating basic research into better mental health 

and mental health care, NIMH needs to foster further methodological adaptation, 

development, and dissemination.

Methodological issues can best be resolved when the full community of scientists, using 

appropriately and creatively a wide range of approaches, comes together in a spirit of 

cooperative problem solving. No one methodological or theoretical approach can be 

expected to provide all answers to the set of issues that must be addressed. It 

therefore is essential to recruit a very wide range of methods (e.g., quantitative, 

epidemiological, qualitative, ethnographic, demographic, biostatistical) as well as a wide 

range of theoretical perspectives (cognitive, behavioral, psychopharmacological, 

sociological, economic) to deal with the problems of translational research. This will 

require scientists who have not previously worked together to collaborate. They will 

need to learn each other’s languages and understand each other’s perspectives and 

methods. 

New developments that have grown out of basic research in methodology will help in 

dealing with the complicated study designs and data structures that arise in translational 

research (e.g., study designs and data sets with hierarchical structures, large data sets 

with missing data, data that do not follow a normal distribution, and syntheses of studies 

using a broad range of techniques). With help from NIMH, the following methodological 

domains will benefit particularly from these developments:

 

11 Note: A more detailed and technical version of this section is presented in Appendix E.
45

• Statistical Sampling

Improving the quality of mental health research and its applications in clinical and 

services settings requires placing greater emphasis on external validity as an 

objective in the research design. Statistical sampling methods should be used more 

comprehensively to enhance the representativeness of the study samples in the 

design and implementation of research studies, outside of narrowly focused 

laboratory studies (usually based on convenience samples of volunteers). 

Behavioral science can potentially strengthen these methods through better 

understanding of the complex behavioral processes involved in participant 

recruitment, nonresponse, and attrition, and can provide techniques to increase 

external validity for research studies. 

• Risk Assessment

The important and complex problem of assessing and measuring risks for 

undesirable mental health outcomes has vexed mental health research from its 

inception, and progress has been slower than desired. Improvements in 

methodological approaches to this problem are essential. Methodological issues 

that must be considered by NIMH include: (1) the use of retrospective and case 

control designs; (2) obtaining sufficient power to detect rare events; and (3) the need 

for adequately specified models that provide more than simple listings of risk factors 

without attention to potency, timing, and sequence. NIMH also needs to close the 

gaps separating the various communities of scientists working on the problem of risk 

assessment in the mental health field, particularly mental health epidemiologists, 

those who study development and psychopathology, and those who design and 

study preventative interventions. Lack of communication and integration hampers 

building a cumulative knowledge base and interferes with the progression of 

research from risk identification to intervention development, to tests of causal 

models hypothesized from basic research. 

• Individual-Differences vs. Group-Differences Approaches

Most studies conducted to understand the potential value of clinical phenomena, 

interventions, or prevention programs use a "mean-difference" approach that, 

although important, is incomplete for clinical understanding because it does not 

address: (1) the numbers of individuals who prosper more under one treatment than 

under another; and (2) those for whom certain approaches work--and under what 

conditions. 

Unfortunately, as in the rest of health care research, individual differences have not 

been well studied in most mental health clinical trials. Current analytic approaches 

need to be complemented by others that can reveal efficiently "What works for whom 

and under what circumstances?" Answering this question requires methods other 

than group-mean comparisons, as well as careful use of exploratory approaches. 

There are many promising methods that may prove helpful, but the problem of 
46

building models for these inquiries has not yet been completely solved. Clearly, 

NIMH needs to make more efforts to adapt, develop, and disseminate analytic 

methods to meet these goals.

F. COMMUNICATING AND DISSEMINATING BEHAVIORAL TRANSLATIONAL 

RESEARCH

As noted in Section A of this chapter, NIMH has an active role to play in disseminating 

information to many audiences and stakeholder groups. Its communication activities 

can include encouraging the exchange of behavioral translational findings, methods, 

and research tools across scientific disciplines and fostering their targeted development 

and adaptation for practitioners, payers, and policymakers. Communicating 

appropriately the results of research to lay and professional audiences is also a vital 

Institute function. 

• Communicating with Scientists

NIMH needs to explore the use of new technologies for communication among 

researchers to extend beyond journal-based sources and face-to-face meetings. It 

should invest directly in providing the infrastructure to permit researchers to hold 

virtual meetings, whether through the World Wide Web or through Web-supported 

teleconferencing. NIMH could establish translational research expertise banks--

through the Internet and other mechanisms--to make expert translational advice 

available to prospective grantees and trainees. NCI offers an “ask the researcher” 

chat room where a methodologist or substantive expert is available to answer 

questions from prospective applicants or grantees. Such an innovation would be a 

cost-effective way for NIMH to help researchers gain access to the skills needed to 

enter new areas of interest. A chat room could aid in forming partnerships among 

researchers investigating similar topics, and a Web site could aid in matching 

researchers and applied research opportunities, with NIMH staff also identifying 

potential collaborators. 

NIMH also should sponsor opportunities for researchers to meet with care providers 

and health care system representatives to discuss implementation of research or 

further testing for effectiveness in actual clinical settings. Such opportunities should 

seed future research plans that result in improved patient care. 

The Institute should consider Web teleconferencing for grant-related work, review 

meetings, and workshops (also a cost savings). Recent explorations of the 

possibility of developing an NIH-based e-journal may have important implications for 

rapid dissemination of NIMH research; an e-journal of NIMH translational research is 

one option to be considered. 
47

• Communicating with Consumers and Practitioners

The Institute recently evaluated its communication efforts to improve outreach to key 

stakeholders. Such efforts should be continued on an ongoing basis to strengthen 

the effectiveness of its dissemination programs. New behavioral technologies, as 

well as the results of the Institute's newly established dissemination research 

program, can provide guidance for reaching the public with research-based mental 

health messages. Does the public receive and retain such information and, most 

important, does it change to more appropriate behavior? Research on access, 

retention of information, and behavior change can suggest ways to shape the 

Institute's communications efforts for many critical target groups, including 

practitioners.

• Listening to Nonscientist Experts

Communication is a two-way street; a strong emphasis on the Institute's research 

dissemination role should not obscure the importance of listening to the needs and 

knowledge of its many stakeholders, including consumers, practitioners, payers, and 

policymakers. The Institute should seek out through a variety of mechanisms--

small-group meetings, public forums, focus groups, and advisory groups--the 

experience of those who use or would want to use behavioral research findings to 

address issues related to clinical care. These experiences can educate NIMH staff 

and researchers to the realities of public health need as it is experienced in everyday 

life, and can sharpen the practical focus of translational research sponsored by the 

Institute. By acknowledging the expertise of nonscientists as partners in the 

translational research enterprise, the Institute also encourages greater willingness of 

these groups to participate in and adopt research they regard as relevant to their 

interests. A potentially important extension of the Institute's willingness to recognize 

the relevant contribution of nonscientists would be its pilot support of communitygenerated research, as outlined in Section C above in "Forming and Supporting New 

Alliances for Research." 

G. EVALUATING PROGRESS IN DEVELOPING BEHAVIORAL TRANSLATIONAL 

RESEARCH

Effective development of a program of translational research at NIMH, be it in the 

behavioral, genetic or neuroscience areas, requires ongoing assessments of:

• What is in the portfolio?

• What is known and not known in the research literature?

• What new opportunities are emerging?

• Who is and should be working in the field?
48

• What are the measurable goals for each program initiative? 

• Who will monitor progress toward program goals?

• Are the program goals being met? Why or why not?

As noted in Chapter II, as a first step, NIMH should identify immediately its baseline 

portfolio in the three priority areas identified in this report, and should develop a plan for 

evaluating success in stimulating research in these areas. After the program has had a 

reasonable time to gain a foothold--perhaps within a decade--its progress and impact on 

the field should be reassessed. Tracking progress against some nontargeted areas as 

“controls” would provide a useful comparison. 

Chapter III and Sections A-G of this chapter have addressed, respectively, the promise 

of behavioral translational research and the leadership issues NIMH must address to 

realize that potential for people with mental illness. Because, as this chapter argues, 

comprehensive NIMH leadership is needed to fulfill the promise of behavioral 

translational research, the Institute should consider implementing in their entirety the 

Workgroup's specific recommendations presented in the action plan to follow.

H. AN ACTION PLAN FOR NIMH

Given the Workgroup's assessment of opportunities and needs for behavioral 

translational research, as well as the current barriers impeding the development of such 

research, the following action plan is presented for consideration by the NAMHC and 

the NIMH Director:

RECOMMENDATION 1. To establish and publicize translational behavioral science 

research as a priority funding area for NIMH and to develop a coherent strategy for its 

systematic development:

a. Develop requests for applications (RFAs) to jump-start research in each of 

the funding priority areas identified in this report, starting first with Priority 

Area 1: Basic Behavioral Processes in Mental Illness. 

b. Issue an RFA to translate basic risk and behavioral process research into 

new interventions aimed at the prevention and treatment of mental disorders 

and related problems. 

c. Develop an implementation plan for long-term development of research in the 

three priority areas of translational research.

d. Commission a "snapshot" of the current status of translational research in the 

NIMH portfolio in the research priority areas. This snapshot would serve as a 

baseline for evaluating the success of research stimulation efforts.
49

e. Convene workshops/conferences that bring together experts in basic 

behavioral research, clinical research, and services research, as well as 

consumers, family members, providers, health systems representatives, 

policymakers, and researchers from allied areas to identify specific areas of 

promise for translational research within the priority areas. 

f. Use new and existing mechanisms [e.g., research reviews, special 

workshops, RFAs, requests for proposals (RFPs), and program 

announcements (PAs)] to stimulate continuing development of translational 

research (including reinvigorating existing research initiatives in areas such 

as dissemination research, human subject protections, and services 

research) and the tools needed to conduct such research.

 

 g. Develop a plan for behavioral translational research that addresses

 communication to and among scientists as well as research dissemination to

 the public, to practitioners, and to other health care personnel. That plan

 should include articles on research opportunities in this area for publication in

 scientific journals that reach a broad audience of basic behavioral, clinical,

 and services researchers. 

RECOMMENDATION 2. Stimulate NIMH-funded research centers to provide an 

infrastructure for new research, speed the translation of findings, and encourage 

interaction across basic, clinical, and services research:

a. Offer competitive supplements (e.g., for access to patients, laboratory 

equipment, clinical trials) to existing NIMH research center programs to:

• Emphasize the integration of behavioral science in basic, clinical, and 

services research, as well as greater interaction at the interface between 

behavioral and biological science; and

• Encourage studies that apply and test basic behavioral processes in 

understanding, identifying, treating, or preventing mental disorders.

b. Create, as needed, new research centers--with specified goals and finite life 

spans.

RECOMMENDATION 3. Develop innovative approaches to supporting translational 

research:

a. Invite current basic behavioral scientist grantees to apply for supplements 

to include research on clinical populations in their studies, and current 

clinical and services research grantees to apply for supplements to include 

research on process, functioning, and/or context in their studies. These 

supplements could be competitive or administrative, undergoing an 

expedited, in-house review. 
50

b. Offer mechanisms for the addition of basic behavioral scientists to

ongoing clinical and services research at academic, provider, state, and

 local settings and for the addition of clinical and services researchers and 

clinicians to basic behavioral research. 

c. Encourage community-based research on mental disorders through small 

developmental grants to local and state governments, communities, or 

businesses working in partnership with academic researchers.

 d. Revise and expand the focus of the B/START (Behavioral Science Track 

Award for Rapid Transition) and RAPID (Rapid Assessment Post-Impact of 

Disaster) announcements to expedite the submission, review, and funding 

of initial pilot efforts for translational research in clinical settings.

e. Commission technologies, tools, and other products identified as

 high-priority needs by mental health consumers and practitioners,

 using mechanisms such as contracts and research grants through the

 Small Business Innovation Research and the Small Business

 Technology Transfer programs. 

RECOMMENDATION 4. Encourage the development, synthesis, and dissemination of 

cumulative behavioral scientific knowledge on mental illness: 

 a. Conduct behavioral research syntheses in priority areas and disseminate

these widely, in appropriately tailored formats, to various audiences of 

stakeholders. 

b. Use meetings as a strategic tool for advancing translational science, with 

a stated goal and work product, and a plan for including representation 

from all relevant stakeholder communities. 

c. Use new technologies to support virtual meetings when appropriate (e.g., 

chat rooms with consultant experts for potential applicants interested in 

designing research) and to disseminate reports of meetings. 

RECOMMENDATION 5. Train researchers at all career levels (predoctoral and 

postdoctoral students, as well as established researchers/faculty) to conduct 

translational behavioral research: 

a. Support research education programs that provide opportunities for

 basic behavioral and social science students and faculty to interact

with clinical and services research students and faculty, exchanging basic, 

clinical, and services research course work and expertise. Include courses 

on new state-of-the-art behavioral science methods and clinical nosology, 

and ideally involve faculty exemplars who combine basic behavioral 

research expertise with expertise in clinical, services, and/or policy issues. 
51

b. Foster individual fellowship programs and career awards that require two 

mentors, one in the basic research arena and one in the clinical/services 

research arena. By doing so, individuals at all stages of their careers would 

be encouraged to develop skills in translational research.

c. Support research education programs that provide short-term training to 

enable established basic behavioral researchers to learn about clinical and 

services research, and clinical and services researchers to learn about 

basic behavioral research. If feasible and appropriate, this might include a 

rotation at the NIMH intramural research program. 

d. Revise training grant policies to permit payment for teaching 

 in translational research training programs that draw faculty from

 many departments and from clinical/service settings. 

. 

 e. Establish translational research expertise banks--through the Internet

 and other mechanisms--to make expert translational advice available

 to prospective grantees and trainees (see 4(c) above). 

 f. Give priority, in funding translational training grants, fellowships,

 research education grants, and career awards, to outstanding

 training programs positioned to bridge basic, clinical, and services

 research in mental health. 

RECOMMENDATION 6. Encourage fair and expert review of translational

behavioral research applications:

a. Prepare reviewers at NIMH and the National Institutes of Health’s (NIH’s) 

Center for Scientific Review (CSR) to assess translational research 

projects.

b. Include among the evaluation criteria for applications submitted in 

response to RFAs the expected impact of the proposed research in 

improving public health.

 

c. Encourage a new orientation process that gives reviewers

 excellent syntheses of research areas, addresses the technical

 and review issues in new research priority areas, and provides

 information on the current portfolio and program initiatives,

 and the programmatic objectives for moving the portfolio

 forward. 

 d. Ensure that for each application, reviewers collectively have appropriate

 expertise in basic, clinical, services, and other relevant research

 areas.
52

RECOMMENDATION 7. Facilitate appropriate and rapid funding of outstanding 

translational research: 

a. Implement a rapid revision and program review process for well-scored 

applications that can be easily corrected without requiring the delay of an 

additional submission and review.

b. Encourage cross-divisional technical assistance, as needed, and give 

special consideration to the funding of translational projects having both 

basic and intervention research components.

RECOMMENDATION 8. Stimulate and disseminate relevant methods to improve the 

capacity for research translation.

a. Foster the appropriate use of existing methods and the development and 

dissemination of new approaches by supporting research that:

• Develops psychometrically sound measures of basic behavioral 

processes, functioning, and context that are appropriate for use in 

clinical and service settings.

• Uses statistical sampling methodologies more comprehensively to 

enhance the external validity of research findings.

• Introduces epidemiological methods of risk identification

 into behavioral risk-factor studies.

• Adapts and develops statistical methods to facilitate the study of effect

 modifiers and individual differences as well as other approaches 

 focused on the issue of “for whom and under what conditions.” 

• Encourages coordination among studies to facilitate

 research synthesis.

 b. Upgrade the quality of diagnosis by issuing RFAs or RFPs calling for

psychometrically sound clinical assessment tools for practitioners, based 

upon contemporary measurement theory.

RECOMMENDATION 9. Improve policy decision-making processes regarding the 

delivery of mental health services and the utility of research data:

a. Support research that makes creative linkages between mental health 

services delivery questions and the behavioral research literatures of

organization, marketing, and decision science.
53

b. Support research that combines state-of-the-art quantitative and qualitative 

 measurement approaches to improve the quality of care. 

RECOMMENDATION 10. Identify which treatments work for whom, under what 

circumstances, and why, to aid in improving mental health services and reducing 

disparities in mental health care:

a. Support translational research that incorporates the theoretical 

 perspectives and methodological approaches of the social and

 behavioral sciences into research addressing fundamental 

 questions in mental health intervention and services research. 

b. Increase research on mental health disparities that includes

 contextual variables--such as ethnicity, social class, and culture. 

 

RECOMMENDATION 11. Expand NIMH staffing resources by inviting behavioral 

scientists to participate in part-time consultancies or to serve as temporary visiting staff.

RECOMMENDATION 12. Monitor the effectiveness of NIMH in improving its 

translational research portfolio:

a. Develop a plan for evaluating success in implementing the three research

and funding priorities of this report. 

b. Evaluate NIMH’s dissemination efforts to assess and improve outreach to

key stakeholders.

I. CONCLUDING COMMENTS

The mysteries of mental illness have never been closer to solution than now, at the 

dawning of the 21st century. This exciting time of discovery offers abundant 

opportunities to increase scientific knowledge about behavior and the brain in health 

and illness. That knowledge, intriguing in its own right, can and must be used to save 

and enhance the lives of millions of Americans burdened by mental disorders and 

millions more at risk of illness.

The NIMH is uniquely positioned to translate scientific achievement in behavioral 

research into clinically relevant advances. But it must deploy wisely and consistently a 

powerful array of persuasive and communicative mechanisms to create the novel and 

sometimes risky collaborations and research paths essential to translational research. 

The Behavioral Science Workgroup offers to Dr. Hyman and the NAMHC an action plan 

outlining a practical strategy for enhancing the clinical contributions of behavioral 

science to change the face of mental health care in America. 
54

V. References and Further Reading

Baxter, L.R., Schwartz, J.M., Bergman, K.S., Szuba, M.P., Guze, B., Mazziotta, 

J.C., Alazraki, A., Selin, E.C., Ferng, H.K., Munterd, P., & Phelps, M.E. (1992). 

Caudate glucose metabolic rate changes with both drug and behavior therapy for 

obsessive compulsive disorder. Archives of General Psychiatry, 49:681-689. 

Behrens, J.T. (1997). Principles and procedures of exploratory data analysis. 

Psychological Methods, 2(2):131-160.

Cohen, G., & Faulkner, D. (1988). The effects of aging on perceived and generated 

memories. In: Poon, L.W., Rubin, D.C., & Wilson, B. (Eds.) Cognition in Adulthood 

and Later Life. New York: Cambridge University Press.

Conway, M.A., & Dewhurst, S.A. (1995). Remembering, familiarity, and source 

monitoring. Quarterly Journal of Experimental Psychology, 48:125-140.

Cuthbert, D. (1959). Use of half-normal plots in interpreting two-level experiments. 

Technometrics, 1(4):311-341.

Danlon, J.-M., Rizzo, L., & Bruant, A. (1999). Functional mechanisms underlying 

impaired recognition memory and conscious awareness in patients with 

schizophrenia. Archives of General Psychiatry, 56:639-648.

Duan, N., Manning, W.G., Jr., Morris, C.N., & Newhouse, J.P. (1983). A comparison 

of alternative models for the demand for medical care. Journal of Business and 

Economic Statistics, 1(2):115-126.

Gibbons, R.D., & Hedeker, D. (1994). Application of random-effects probit 

regression models. Journal of Consulting Clinical Psychology, 62(2):285-296.

Glisson, C., & Hemmelgarn, A. (1998). The effects of organizational climate and 

interorganizational coordination on the quality and outcomes of children’s service 

systems. Child Abuse & Neglect, 22(5):401-421.

Guarnaccia, P., & Rogler, L. (1999). Research on culture-bound syndromes: New 

directions. American Journal of Psychiatry, 156(9):1322-1327.

Hogarty, G.E., Greenwald, D., Ulrich, R.F., Kornblith, S.J., DiBarry, A.L., Cooley, S., 

Carter, M., & Flesher, S. (1997). Three-year trials of personal therapy among 

schizophrenic patients living with or independent of family. II. Effects on adjustment 

of patients. American Journal of Psychiatry, 154(11):1514-1524.
55

Kolb, B., & Whishaw, I.Q. (1998). Brain plasticity and behavior. Annual Review of 

Psychology, 49:43-64.

Kring, A.M., & Neale, J.M. (1996). Do schizophrenic patients show a disjunctive 

relationship among expressive, experiential, and psychophysiological components 

of emotion? Journal of Abnormal Psychology, 105(2):249-257.

Lewis-Fernandez, R., & Kleinman, A. (1995). Cultural psychiatry: Theoretical, 

clinical, and research issues. Psychiatric Clinics of North America,18(3): 433-48.

Lyubomirsky, S., & Nolen-Hoeksema, S. (1995). Effects of self-focused rumination 

on negative thinking and interpersonal problem solving. Journal of Personality and 

Social Psychology, 69:176-190.

Metcalfe, J., & Shimamura, A.P. (Eds.) (1994). Metacognition: Knowing about 

Knowing. Cambridge: Massachusetts Institute of Technology Press.

Murray, C.J.L., & Lopez, A.D.L. (Eds.) (1996). Summary: The Global Burden of 

Disease. Cambridge: Harvard University Press.

National Advisory Mental Health Council. (1996). Basic Behavioral Science 

Research for Mental Health: A National Investment: A Report of the National 

Advisory Mental Health Council. Bethesda, MD: National Institutes of 

Health/National Institute of Mental Health. NIH Publication No. 96-3682.

National Advisory Mental Health Council Clinical Treatment and Services Research 

Workgroup (1999). Bridging Science and Service: A Report by the National 

Advisory Council's Clinical Treatment and Services Research Workgroup. (1999). 

Bethesda, MD. National Institutes of Health/National Institute of Mental Health. NIH 

Publication No. 99-4353. 

National Institute of Mental Health Genetics Workgroup (1998). Genetics and 

Mental Disorders: Report of the National Institute of Mental Health's Genetics 

Workgroup. Bethesda, MD: National Institutes of Health/National Institute of Mental 

Health. NIH Publication No. 98-4268.

Olguin, J. (1997). A new look at half-normal plots for assessing the significance of 

contrasts for unreplicated factorials. Applied Statistics, 46(4):449-462.

Rothman, A.J., & Salovey, P. (1997). Shaping perceptions to motivate healthy 

behavior: The role of message framing. Psychological Bulletin,121:3-19.

Strauman, T.J. (1996). Self-beliefs, self-evaluation, and depression: A perspective 

on emotional vulnerability. In: Martin, L., & Tesser, A. (Eds.) The cognitive sciences 

and psychotherapy [Special Issue]. Journal of Psychotherapy Integration, 4:291-

316.
56

Susser, E., Valencia, E., Berkman, A., Sohler, N., Conover, S., Torres, J., Betne, P., 

Felix, A., & Miller, S. (1998). HIV sexual risk reduction in homeless men with mental 

illness. Archives of General Psychiatry, 55:266-272.

U.S. Department of Health and Human Services. (1999). Mental Health: A Report 

of the Surgeon General. Rockville, MD: U.S. Department of Health and Human 

Services, Substance Abuse and Mental Health Services Administration, Center for 

Mental Health Services, National Institutes of Health, National Institute of Mental 

Health.

Ware, N.C., Tugenberg, T., Dickey, B., & McHorney, C.A. (1999). An ethnographic 

study of the meaning of continuity of care in mental health services. Psychiatric 

Services, 50(3):395-400.
57

VI. APPENDICES

APPENDIX A

OBSSR* DEFINITION OF BEHAVIORAL AND SOCIAL SCIENCES

RESEARCH FOR NIH

Core Areas of Behavioral and Social Sciences Research

The core areas of behavioral and social sciences research are those that have a major 

and explicit focus on the understanding of behavioral or social processes, or on the use 

of these processes to predict or influence health outcomes or health risk factors. These 

core areas of research are divided into basic (or fundamental) research and clinical 

research. 

I. Basic or Fundamental Research 

Basic research in the behavioral and social sciences is designed to further our 

understanding of behavioral and social functioning. As is the case for basic research in 

the biomedical sciences, basic behavioral and social sciences research does not 

address disease outcomes per se, but is designed to provide essential knowledge 

necessary for better prediction, prevention, and control of illnesses. 

Basic behavioral and social sciences research is divided into three categories: 

(A) research on behavioral and social processes; (B) biopsychosocial research;

and (C) research on the development of behavioral or social procedures for 

measurement, analysis, and classification. 

A. Research on behavioral and social processes involves the study of human or animal 

functioning at the level of the individual, small group, institution, organization, or 

community. At the individual level, this research may involve the study of behavioral 

factors such as cognition, memory, language, perception, personality, emotion, 

motivation, and others. At higher levels of aggregation, it includes the study of 

social variables such as the structure and dynamics of small groups (e.g., couples, 

families, workgroups, etc.); institutions and organizations (e.g., schools, religious 

organizations, etc.); communities (defined by geography or common interest); and 

larger demographic, political, economic, and cultural systems. Research on 

behavioral and social processes also includes the study of the interactions within 

and between these two levels of aggregation, such as the influence of sociocultural 

factors on cognitive processes or emotional responses. Finally, this research also 

includes the study of environmental factors such as climate, noise, environmental 

hazards, and residential environments and their effects on behavioral and social 

functioning. 

 

*

 NIH Office of Behavioral and Social Sciences Research
58

Examples of research topics and their implications include:

 Sensation and perception 

(Implications: neurological disorders and disorders associated

 with vision, hearing, taste, and smell) 

 Emotion and motivation 

(Implications: depression, anxiety, schizophrenia, conduct disorders, normal 

psychological development, eating disorders, obesity, addictions, sleep 

disturbances, behavioral and cognitive treatments) 

 Vulnerability and resilience 

 (Implications: psychopathology, violence, effects of child abuse and 

neglect)

 Attention, learning and memory 

(Implications: attention deficit disorders, learning disabilities, Alzheimer's

disease and other dementias, cognitive rehabilitation, education) 

 Language development 

 (Implications: communication disorders, learning disabilities) 

 Social influences and social cognition 

 (Implications: all-cause mortality, psychopathology, behavioral and 

cognitive treatments) 

 Family processes and social networks 

(Implications: domestic violence, divorce, child abuse, psychopathology, 

all-cause mortality, child development, aging) 

 Sociocultural and environmental processes 

(Implications: better understanding of social, cultural, and 

environmental antecedents to mental and physical illnesses) 

B. Biopsychosocial research (also known as biobehavioral or biosocial research)

involves the study of the interactions of biological factors with behavioral or social 

variables and how they affect each other (i.e., the study of bidirectional multilevel

 relationships).

 Examples of research topics and their implications include: 

 Behavior genetics 

(Implications: addictions, psychopathology, heart disease, 

gene expression, cancer risk, diabetes, oral health) 
59

 Behavioral and cognitive neurosciences 

 (Implications: effects of brain injury, neurodegenerative diseases,

learning disabilities, dementia, addictions, sleep disorders, 

schizophrenia, neurological development, and plasticity) 

 Psychoneuroimmunology 

 (Implications: stress effects on health, AIDS, dental problems,

 infections) 

 Psychopharmacology 

 (Implications: addictions, psychopathology, brain disorders, 

drug treatments) 

 Behavioral cardiology 

 (Implications: cardiovascular diseases, stroke, hypertension) 

C. Research on the development of procedures for measurement, analysis, and 

classification involves the development and refinement of procedures for measuring and 

analyzing behavior, psychological functioning, or the social environment. This research 

is designed to develop research tools that could be used in other areas of behavioral 

and social sciences or in biomedical research.

 Examples of research topics in the area include:

 Statistical modeling techniques

 Memory assessment

 Behavioral observation procedures

 Psychometric analysis self-report instruments

 Qualitative and ethnographic methods

 Neuropsychological assessment

 Psychophysiological methods

 Pain assessment

 Instruments for determining dietary intake

 

 Assessment of medical adherence
60

II. Clinical Research

Clinical research in the behavioral and social sciences is designed to predict or 

influence health outcomes, risks, or protective factors. It is also concerned with the 

impact of illness or risk for illness on behavioral or social functioning.

Clinical research is divided into five categories: (A) research on the identification and 

understanding of behavioral and social risk and protective factors associated with the 

onset and course of illness, and with health conditions; (B) research on the effects of 

illness or physical condition on behavioral and social functioning; (C) treatment 

outcomes research; (D) research on health promotion and disease prevention; and 

(E) research on institutional and organizational influences on health.

A. Research on the identification and understanding of behavioral and social risk and 

protective factors associated with the onset and course of illness, and with health 

conditions examines the association of specific behavioral and social factors with 

mental and physical health outcomes, and the mechanisms that explain these 

associations. It is concerned with behavioral and social factors that may be healthdamaging (risk factors) or health-promoting (protective factors).

Examples of research topics in this area include the study of such risk and protective 

factors as:

 Smoking

 Dietary practices

 Physical inactivity

 Stress

 Substance abuse

 Social support

 Cultural practices

 Socioeconomic status

B. Research on the effects of illness or physical condition on behavioral and social 

functioning.

 Examples of research topics include such areas as:

 Psychological and social consequences of genetic testing
61

 Behavioral correlates of head injury across developmental stages

 Emotional and social consequences of HIV infection or cancer

 Coping responses associated with chronic pain syndromes

 Effects of illness on economic status

 Coping with loss of function due to disability

C. Treatment outcomes research involves the design and evaluation of behavioral and 

social interventions to treat mental and physical illnesses, or interventions designed to 

ameliorate the effects of illness on behavioral or social functioning. This area also 

includes research on behavioral and social rehabilitation procedures.

 Examples of research topics in this area include: 

 Cognitive or behavioral interventions for anxiety

 disorders and depression

 Strategies to reduce arthritis pain

 Interventions for restoring behavioral and brain

 functioning following head injury

 Lifestyle (dietary change, exercise, stress reduction)

 approaches to reversing coronary atherosclerosis

 Procedures to enhance adherence to medical

 interventions

D. Research on health promotion and disease prevention involves the design, 

implementation, and evaluation of behavioral and social interventions to prevent the 

occurrence, recurrence, or progression of illness, symptoms, risk factors, or health 

problems. Health promotion also consists of evaluating procedures that facilitate 

optimal health functioning.

 Examples of research topics in this area include:

 Design and evaluation of programs to discourage

 adolescent smoking

 Approaches to increase physical activity in the elderly

 Interventions to alter dietary intake to promote health
62

 Family interventions to prevent injuries in children

 Teaching parenting skills to prevent sudden infant

 death syndrome

 Mass media interventions to promote health

 knowledge

 Promoting the use of condoms to prevent sexually

 transmitted diseases

E. Research on institutional and organizational influences on health includes studies of 

the organization of and access to health care, its effectiveness in real world settings 

(e.g., health services research), its cost efficiency, and its social and cultural 

acceptability. It also involves research on macro-economic phenomena (e.g., business 

cycles), community and neighborhood organization and the structure and functioning of 

families, and how these variables influence the consumption and choice of health care, 

and decision making concerning health procedures. Finally, this category includes 

research on how successful approaches to the organization and delivery of health 

services can be translated into public policy.

 Examples of research topics in this area include: 

Impact of providing inpatient smokers with information and

brief counseling from nursing staff

Accessibility of rural dental health care facilities for

migrant workers

Cost-effectiveness of occupational safety interventions

Use of schools as sites for the delivery of mental

 health services

Effects of capitation on health care utilization

Effects of ethnicity and gender on referral for

 mental health services

Association of health provider behavior to

 patient adherence to medical treatments
63

III. Adjunct Areas of Behavioral and Social Sciences Research

Adjunct behavioral and social sciences research areas are determined by two sets of 

criteria. First, these research areas do not have a major and explicit focus on the 

understanding of behavioral or social processes, or the use of these factors to predict or 

influence health outcomes or health risk factors. That is, these projects cannot be 

categorized as basic or clinical behavioral and social sciences research. Second, 

adjunct behavioral and social sciences research does include studies that have clearly 

articulated implications for either understanding behavioral or social processes (in the 

case of some basic biological research), or that utilize behavioral and social factors as 

critical outcome variables (in the case of behavior-relevant pharmacologic studies). 

The inclusion of adjunct research areas in this definition is an acknowledgment that 

there are scientific domains outside of the core areas of behavioral and social sciences 

where (a) the findings have clear implications for understanding behavioral and social 

processes, or (b) the research is an outgrowth of prior behavioral or social sciences

research. Although it could be argued that these adjunct areas are really in the 

"biomedical" research domains, they nevertheless represent research topics that are 

inextricably linked to the behavioral and social sciences. Adjunct behavioral and social

sciences research is divided into two categories: (A) Behavior-relevant basic biological 

research, and (B) Behavior-relevant pharmacologic intervention studies. 

A. Behavior-relevant basic biological research involves studies where the 

understanding of behavioral and social process is a clearly articulated goal. Although 

these studies focus solely in the biological level of analysis (i.e., no behavioral or social 

measures are taken), they are designed explicitly to provide a better understanding of 

basic behavioral, social, or biopsychosocial processes (see sections I.A. and I.B.), and 

typically involve independent variables known to be important to behavioral or social 

functioning. These types of biological studies are often designed to assist in identifying 

biological mechanisms that mediate associations between behavioral and social factors 

with health outcomes. Specifically excluded from this category is research that focuses 

solely on biological mechanisms underlying clinical problems that have behavioral 

components (e.g., depression, schizophrenia). That is, to be included in this category, 

the research must address basic behavioral, social, or biopsychosocial processes. 

 Examples of research topics in this area include:

 Studies of neural plasticity designed to improve understanding of

behavioral or cognitive development

 Studies of the sympathetic nervous system designed

 to better understand stress/health relationships

 Studies of brain regions potentially involved in emotion
64

Studies of endocrine/immune system interactions designed to enhance 

understanding of psychoneuroimmunological associations

B. Behavior-relevant pharmacologic intervention studies include those studies that 

evaluate drug treatment for mental or physical health problems, where a behavioral or 

social dependent variable is used (e.g., anxiety, depression, drinking behavior, smoking, 

etc.). These types of pharmacologic intervention studies have clearly benefited from 

behavioral and social sciences research, especially with respect to measurement of 

outcomes. This research is relevant to the behavioral and social sciences not only 

because behavioral and social outcomes variables are used, but because it facilitates 

an understanding of the biological mechanisms underlying those processes.

 Examples of research topics in this area include: 

 Effects of chemotherapeutic treatments on quality of life

 Psychopharmacologic treatments for anxiety and depression

 Side effects of drug treatments on medical compliance

 Pharmacologic approaches to nicotine addiction
65

APPENDIX B

NATIONAL ADVISORY MENTAL HEALTH COUNCIL

CHAIRPERSON

Steven E. Hyman, M.D.

Director

National Institute of Mental Health

Bethesda, Maryland

EXECUTIVE SECRETARY

Jane A. Steinberg, Ph.D.

Acting Director

Division of Extramural Activities

National Institute of Mental Health

Bethesda, Maryland

MEMBERS

Thomas J. Coates, Ph.D. 

Professor 

Director, UCSF AIDS Research Institute 

 and Center for AIDS Prevention Studies

University of California, San Francisco

San Francisco, California 

Kathy Cronkite

Mental Health Advocate

Austin, Texas

Mary L. Durham, Ph.D. 

Vice President/Research

Kaiser Foundation Hospitals

Portland, Oregon

Mary Jane England, M.D. 

President

Washington Business Group on Health

Washington, DC

Javier I. Escobar, M.D. 

Professor and Chairman

University of Medicine and Dentistry of New

 Jersey

Robert Wood Johnson Medical School

Piscataway, New Jersey

Ellen Frank, Ph.D. 

Professor of Psychiatry and Psychology

Department of Psychiatry

School of Medicine

University of Pittsburgh

Pittsburgh, Pennsylvania

Apostolos Georgopoulos, M.D., Ph.D.

Professor, Department of Neuroscience, 

 Neurology and Psychiatry

University of Minnesota Medical School

Director, Brain Sciences Center 

Veterans Administration Medical Center

Minneapolis, Minnesota 

Deborah M. Harrison 

Mental Health Advocate

Potomac, Maryland

Henry Lester, Ph.D. 

California Institute of Technology

Division of Biology 

Pasadena, California

James McClelland, Ph.D. 

Co-Director

Center for the Neural Basis of Cognition

Carnegie Mellon University

Pittsburgh, Pennsylvania

Charles B. Nemeroff, M.D., Ph.D. 

Reunette W. Harris Professor and Chair

Department of Psychiatry and Behavioral 

 Sciences

Emory University School of Medicine

Atlanta, Georgia 
66

Anne C. Petersen, Ph.D. 

Senior Vice President for Programs

W. K. Kellogg Foundation

Battle Creek, Michigan

A. John Rush, M.D. 

Professor, Betty Jo Hay Distinguished Chair

Department of Psychiatry

Southwestern Medical Center

University of Texas

Dallas, Texas 

Edward Scolnick, M.D. 

President

Merck Research Laboratories

West Point, Pennsylvania

Joseph S. Takahashi, Ph.D. 

Investigator, Howard Hughes Medical 

 Institute

Walter and Mary E. Glass Professor

Department of Neurobiology and Physiology

Northwestern University

Evanston, Illinois 

James G. Townsel, Ph.D. 

Professor and Director

Center for Molecular and Behavioral

 Neuroscience

School of Medicine

Meharry Medical College

Nashville, Tennessee 

Myrna M. Weissman, Ph.D. 

Professor

Department of Clinical and Genetic

 Epidemiology 

New York State Psychiatric Institute

Columbia University

New York, New York 

Roy C. Wilson, M.D. 

Director

Missouri Department of Mental Health

Jefferson City, Missouri

EX OFFICIO MEMBERS

Office of the Secretary, DHHS

Donna E. Shalala, Ph.D.

Secretary

Department of Health and Human 

 Services

Washington, DC 

National Institutes of Health

Ruth Kirschstein, M.D.

Acting Director

National Institutes of Health

Bethesda, Maryland 

Department of Defense

Robert A. Mays, Jr., Ph.D.

Colonel, U.S. Army

Office of the Inspector General

North Atlantic Regional Medical 

 Command

Walter Reed Army Medical Center

Washington, DC 

Department of Veterans Affairs

Thomas B. Horvath, M.D., F.R.A.C.P.

Chief of Staff 

Veterans Affairs Medical Center

Houston, Texas 

LIAISON REPRESENTATIVE

Thomas H. Bornemann, Ed.D.

Deputy Director

Center for Mental Health Services

Substance Abuse and Mental Health 

 Services Administration

Rockville, Maryland
67

APPENDIX C

NAMHC BEHAVIORAL SCIENCE WORKGROUP

CHAIRPERSON CO-CHAIRPERSON

Anne C. Petersen, Ph.D.*Robert W. Levenson, Ph.D.

Senior Vice President for Programs Professor

W.K. Kellogg Foundation Department of Psychology

Battle Creek, Michigan University of California, Berkeley

Berkeley, California

MEMBERS

 

*

 Members of the NAMHC

**

 Past Member of the NAMHC

Mark I. Appelbaum, Ph.D.

Professor

Department of Psychology 

University of California, San Diego

La Jolla, California 

Naihua Duan, Ph.D.

Professor

Department of Psychiatry & Biobehavioral 

Sciences

University of California, Los Angeles

Los Angeles, California

Mary L. Durham, Ph.D.*

Vice President/Research

Kaiser Foundation Hospitals

Portland, Oregon 

Susan Folkman, Ph.D.

Professor 

School of Medicine

University of California, San Francisco

San Francisco, California 

Richard D. Gonzalez, Ph.D.

Associate Professor

Department of Psychology

University of Michigan

Ann Arbor, Michigan 

Peter J. Guarnaccia, Ph.D.

Associate Professor

Institute for Health Care Policy and

 Aging Research

Rutgers State University of New Jersey

New Brunswick, New Jersey

Dale L. Johnson, Ph.D.**

Professor

Department of Psychology

University of Houston

Houston, Texas

Robert A. Mays, Jr., Ph.D.*

Colonel, U.S. Army

Office of the Inspector General

North Atlantic Regional Medical Command

Walter Reed Army Medical Center

Washington, DC 

Thomas F. Oltmanns, Ph.D.

Professor

Department of Psychology

University of Virginia

Charlottesville, Virginia 

Debra L. Roter, Dr.P.H.

Professor

Department of Health Policy and

 Management

Johns Hopkins School of Public Health

Baltimore, Maryland

Peter Salovey, Ph.D.

Professor of Psychology and of

 Epidemiology and Public Health 

Department of Psychology

Yale University

New Haven, Connecticut 

Nina R. Schooler, Ph.D.

Director of Psychiatry Research 

 at Hillside Hospital

Division of North Shore – Long Island

 Jewish Health System

Glen Oaks, New York 
68

NIMH STAFF TO THE WORKGROUP

STAFF DIRECTOR

Jane A. Steinberg, Ph.D.

Division of Extramural Activities

ASSOCIATE STAFF DIRECTOR

Susan Matthews

Division of Extramural Activities

STAFF WRITER

Anne H. Rosenfeld

Division of Mental Disorders, Behavioral

 Research and AIDS

STAFF EDITOR

Joan Cole

Division of Extramural Activities

STAFF TYPISTS

Betty Nkansah

Division of Extramural Activities

Debra Dabney

Division of Extramural Activities

GRAPHIC DESIGN

Catherine West

Office of Communications and Public

 Liaison

STAFF CONSULTANTS

Della M. Hann, Ph.D.

Division of Mental Disorders, Behavioral

 Research and AIDS

Ann Hohmann, Ph.D.

Division of Services and

 Intervention Research

Doreen S. Koretz, Ph.D.

Office of the Director and

Division of Mental Disorders, Behavioral

 Research and Aids

Carolyn C. Morf, Ph.D.

Division of Neuroscience and Basic

 Behavioral Science

Carmen P. Moten, Ph.D.

Office for Special Populations

Linda L. Street, Ph.D.

Division of Services and Intervention

 Research
69

APPENDIX D

ROSTER OF CONSULTANTS

*

 

*

 The Workgroup appreciates the contribution of the consultants in developing this report; however, 

inclusion in the listing does not necessarily indicate endorsement of the Workgroup’s recommendations. 

In addition, the Workgroup is indebted to the many comments provided by NIMH grantees, other 

researchers, consumers, clinicians, policymakers and others in response to the Workgroup’s invitation.

Norman B. Anderson, Ph.D.

NIH Office of Behavioral and

 Social Sciences Research

William R. Avison, Ph.D.

University of Western Ontario

Elaine Baldwin

Office of Communications and Public 

 Liaison, NIMH

Mary C. Blehar, Ph.D.

Office for Special Populations, NIMH

Michele Cooley Quille, Ph.D.

Johns Hopkins University

Patrick Corrigan, Psy.D.

University of Chicago

Bruce N. Cuthbert, Ph.D.

Division of Mental Disorders, Behavioral

 Research and AIDS, NIMH

Julia Freeman, Ph.D.

National Institute of Arthritis and

 Musculoskeletal and Skin Diseases, NIH

Lisa Goodale, A.C.S.W.

National Depressive and Manic-Depressive

 Association

Laura Lee Hall, Ph.D.

National Alliance for the Mentally Ill

Scott W. Henggeler, Ph.D.

Medical University of South Carolina

Gerard Hogarty, M.S.W.

Western Psychiatric Institute and Clinic

Jan Howard, Ph.D.

National Institute on Alcohol Abuse

 and Alcoholism, NIH

Steven E. Hyman, M.D.

Director, NIMH

Peter G. Kaufmann, Ph.D.

National Heart, Lung, and

 Blood Institute, NIH

Cille Kennedy, Ph.D.

Division of Services and Intervention

 Research, NIMH

 

Howard S. Kurtzman, Ph.D.

Division of Neuroscience and Basic

 Behavioral Science, NIMH

Lawrence W. Lee, M.D.

Association for Science in Autism Treatment

Felice J. Levine, Ph.D.

American Sociological Association

Douglas L. Meinecke, Ph.D.

Division of Neuroscience and Basic

 Behavioral Science, NIMH

Sherry Mills, M.D., M.P.H.

National Cancer Institute, NIH

Steven O. Moldin, Ph.D.

Division of Neuroscience and Basic

 Behavioral Science, NIMH

Joel T. Nigg, Ph.D.

Michigan State University
70

Grayson S. Norquist, M.D., M.S.P.H.

Division of Services and Intervention

 Research, NIMH

Michael W. O’Hara, Ph.D.

University of Iowa

Mary E. Oliveri, Ph.D.

Division of Neuroscience and Basic

 Behavioral Science, NIMH

Lisa S. Onken, Ph.D.

National Institute on Drug Abuse, NIH 

William Sanderson, Ph.D.

Rutgers University

Laura Schreibman, Ph.D.

University of California, San Diego

Lynne Siqueland, Ph.D.

University of Pennsylvania

Michael Stefanek, Ph.D.

National Cancer Institute, NIH

Ellen S. Stover, Ph.D.

Division of Mental Disorders,

Behavioral Research and AIDS, NIMH

Academy of Psychological Clinical Science

June 3, 1999 Meeting

Marc S. Atkins, Ph.D.

University of Illinois, Chicago

Timothy B. Baker, Ph.D.

University of Wisconsin

Howard Berenbaum, Ph.D.

University of Illinois

Richard R. Bootzin, Ph.D.

University of Arizona

Thomas H. Brandon, Ph.D.

University of South Florida

Lynn F. Bufka, Ph.D.

Boston University

Peter R. Finn, Ph.D.

Indiana University

Don C. Fowles, Ph.D.

University of Iowa

William M. Grove, Ph.D.

University of Minnesota

Edward S. Katkin, Ph.D.

SUNY-Stony Brook

Joseph Locastro, Ph.D.

Boston University

Steven Lynn, Ph.D.

SUNY-Binghamton

Richard M. McFall, Ph.D.

Indiana University

Beth Meyerowitz, Ph.D.

University of Southern California

Paul Pilkonis, Ph.D.

Western Psychiatric Institute and Clinic

Janet Polivy, Ph.D.

University of Toronto

John Roitzsch, Ph.D.

Medical University of South Carolina

Karen Schmaling, Ph.D.

University of Washington School of

 Medicine

Lee Sechrest, Ph.D.

University of Arizona

Varda Shoham, Ph.D.

University of Arizona

Robert F. Simons, Ph.D.

University of Delaware

Timothy J. Strauman, Ph.D.

University of Wisconsin Medical School
71

Timothy J. Trull, Ph.D.

University of Missouri

Thomas A. Widiger, Ph.D. 

University of Kentucky

Antonette M. Zeiss, Ph.D.

Veterans Administration Health Care 

System, Palo Alto
72

American Psychological Society

June 4, 1999 Meetings

Elaine A. Blechman, Ph.D.

University of Colorado

Thomas D. Borkovec, Ph.D.

Pennsylvania State University

Marilynn B. Brewer, Ph.D.

Ohio State University

Robert C. Carson, Ph.D.

Duke University

Philip A. Cowan, Ph.D.

University of Iowa

Kay Deaux, Ph.D.

City University of New York

Randall Engle, Ph.D.

Georgia Institute of Technology

Don C. Fowles, Ph.D.

University of Iowa

J. Richard Hackman, Ph.D.

Harvard University

Gregory M. Herek, Ph.D.

University of California-Davis

Carroll E. Izard, Ph.D.

University of Delaware

Edward S. Katkin, Ph.D.

SUNY-Stony Brook

Alan G. Kraut, Ph.D.

American Psychological Society

Neil S. Lutsky, Ph.D.

Carleton College

Richard McFall, Ph.D.

Indiana University

Richard E. Nisbett, Ph.D.

University of Michigan

Janet D. Polivy, Ph.D.

University of Toronto

Henry L. Roediger, III, Ph.D.

Washington University

Jonathan W. Schooler, Ph.D.

University of Pittsburgh

Lee Sechrest, Ph.D.

University of Arizona

Jerome E. Singer, Ph.D.

Uniformed Services University of the

 Health Sciences

Claude M. Steele, Ph.D.

Stanford University

Joseph E. Steinmetz, Ph.D.

Indiana University

Abraham Tesser, Ph.D.

University of Georgia

Richard F. Thompson, Ph.D.

University of Southern California

Thomas A. Widiger, Ph.D.

University of Kentucky

Michele A. Wittig, Ph.D.

California State University
73

American Psychological Association

August 20, 1999 Meeting

Barry Anton, Ph.D.

University of Puget Sound

Daniel Armstrong, Ph.D.

University of Miami

Robert A. Brown, Ph.D.

University of Maryland

Susan Cochran, Ph.D., M.S.

UCLA School of Public Health

Elizabeth Doll, Ph.D.

University of Colorado at Denver

Edward J. Frischholz, Ph.D.

University of Illinois-Chicago

Gordon Gibson, Ph.D.

Center for Behavioral Health 

Robert Jay Green, Ph.D.

California School of Professional 

 Psychology

Mark Kiselica, Ph.D.

The College of New Jersey

Patricia Kobor

American Psychological Association

Richard McCarty, Ph.D.

American Psychological Association

Christopher McLaughlin

American Psychological Association

Michael Murphy, Ph.D.

Indiana State University

Thomas H. Ollendick, Ph.D.

Virginia Polytech Institute and State

University

Walter E. Penk, Ph.D.

Veterans Administration Medical 

Center, Bedford, Massachusetts

Stephen Portuges, Ph.D.

Los Angeles Psychoanalytic Institute

Geoffrey Reed, Ph.D.

American Psychological Association

Maria Riva, Ph.D.

University of Denver

Lizabeth Roemer, Ph.D.

Boston University

Sandra Shullman, Ph.D.

Organizational Horizons

Wayne Silverman, Ph.D.

New York State Institute for Basic

 Research in Developmental Disabilities

Andrea Solarz, Ph.D.

Society for Community Research and Action

Beverly Thorn, Ph.D.

University of Alabama

W. Douglas Tynan, Ph.D.

Pennsylvania State Geisinger

 Medical Center
74

APPENDIX E

NEEDED ADVANCES IN RESEARCH METHODS*

To enhance the application of behavioral science research in clinical and services 

settings and provide data and findings more pertinent to clinical and services 

researchers and practitioners, NIMH needs to assess the adequacy of current methods 

for addressing translational research questions. This assessment should provide a 

basis for integrating and adapting existing methodological tools more effectively, for 

developing new tools as needed, and for identifying effective ways to disseminate them. 

Historically, NIMH has very actively and effectively furthered the methodological basis 

for mental health research (e.g., the work of Gibbons and Hedeker, 1994**). However, 

to keep pace with its new emphasis on translating basic research into better mental 

health and mental health care, NIMH needs to foster further methodological adaptation, 

development, and dissemination. New developments that have grown out of basic 

research in methods will help in dealing with the complicated study designs and data 

structures that arise in translational research (e.g., study designs and data sets with 

hierarchical structures, large data sets with missing data, data that do not follow a 

normal distribution, and synthesis of studies using a broad range of techniques). With 

help from NIMH, the following methodological domains will benefit particularly from 

these developments:

• Statistical Sampling

Improving the quality of mental health research and its applications in clinical and 

services settings requires placing greater emphasis on external validity as an objective 

in the research design. Statistical sampling methods should be used more 

comprehensively to enhance the representativeness of study samples in the design and 

implementation of research outside of narrowly focused laboratory studies (usually 

based on convenience samples of volunteers). The emphasis on statistical sampling, 

representativeness, and external validity is not restricted to survey studies that employ 

structured interviews as the primary data collection vehicle (traditionally the main arena 

for the application of statistical sampling methods). It is equally applicable to clinical 

trials that focus on biological outcomes and studies that focus primarily on qualitative 

data collection methods.

Behavioral science potentially can strengthen these methods through better 

understanding of the complex behavioral processes involved in participant recruitment, 

nonresponse, and attrition, and can provide techniques to enhance external validity for 

research studies. 

 

*

Note: An abridged version of this appendix is presented in Chapter IV. 

**Please refer to earlier references.
75

• Risk Assessment

The problem of assessing and measuring risks for undesirable mental health outcomes 

has vexed mental health research from its inception. The problem is complex and 

difficult, and progress in this domain has been slower than desired. Nonetheless, “risk 

assessment” remains an important problem that begs for solution, and improvements in 

the methodological approaches to this problem are essential. Methodological issues 

that must be considered by NIMH include: (1) the use of retrospective and case control 

designs; (2) dealing with statistical power problems in detecting rare events; and (3) the 

need for adequately specified models that provide more than simple listings of risk 

factors without attention to potency, timing, and sequencing.

NIMH also needs to close the gaps separating the various communities of scientists 

working on the problem of risk assessment in the mental health field. For example, as a 

rule, the work and methods of mental health epidemiologists do not seem to be well 

understood and/or integrated by those who study development and psychopathology, 

and vice versa. Similarly, there seems to be relatively little understanding--and few 

vehicles for cooperation--among these groups and those who design and study 

preventive interventions. Each group, relying heavily on its own research traditions and 

methodologies, gives insufficient attention to the well-established approaches of the 

other sub-fields. As a result, progress in risk assessment is inefficient and built upon 

separate and distinct knowledge bases, hindering the development of cumulative 

knowledge. Lack of integration interferes with the logical progression of research from 

risk identification, to studies of the basic processes that move people from risk to 

psychopathology, to the development of intervention strategies and targets that can test 

causal models hypothesized from the basic research. 

• Individual-Differences vs. Group-Differences Approaches

Most studies conducted to understand the potential value of clinical phenomena, 

interventions, or prevention programs use a “group-differences approach” or the “Food 

and Drug Administration model." They are designed to discover group differences in a 

way that reveals the superiority of one intervention over another. This "meandifference" approach, although important in regulating drug and food products, is 

incomplete for clinical understanding in two arenas. First, it does not address the 

numbers of individuals who prosper more under one treatment than under another. 

Second, it does not address the extremely important issue of identifying those for whom 

certain approaches work--and under what conditions. Even with the most 

straightforward medical treatments, identical treatments do not work equally well for all 

individuals. This probably also is true for the treatment of mental disorders, and these 

effects might be quite large. 

Unfortunately, as in the rest of health care research, individual differences have not 

been well studied in most trials. Current analytic approaches need to be complemented 

by others that can reveal efficiently "what works for whom and under what 

circumstances." All the techniques currently employed to explore this issue require 
76

large samples. For example, intervention researchers must often examine a dauntingly 

large number of interactions between the intervention and potentially important effect

modifiers. More emphasis needs to be placed on the iterative nature of exploratory and 

confirmatory analyses (Behrens, 1997**). Exploratory analyses serve the important role 

of hypothesis generation, to be followed by confirmatory analyses in subsequent studies 

or through the use of “hold out” sample approaches (Duan et al., 1983**).

One potentially useful approach for understanding individual differences is the "halfnormal plot" (Cuthbert, 1959;** Olguin, 1997**) commonly used in agricultural and 

engineering studies to explore interactions in factorial experiments. Another potentially 

useful approach is multilevel modeling, in which individual differences are modeled as a 

random effect. This approach is used widely in provider profiling to assess the 

differences in treatment outcome across providers. The presence of a random effect 

does not explicitly indicate specific effect modifiers, but it is a useful screening 

procedure to determine whether further exploration is likely to be worthwhile. The major 

points, however, are that answering the all-important “for whom and under what 

conditions” question requires methodological approaches other than group-mean 

comparisons and that careful use of exploratory approaches is critical.

Also promising is a group of “research synthesis” approaches--the best known of which 

is meta-analysis. These approaches use the results of collections of studies (with 

insufficient power individually to detect subgroups for whom a treatment has a desired 

effect) to help understand where treatment effects may be concentrated. Approaches 

such as these can be particularly useful when trying to understand how interventions 

affect subsets of the population (e.g., cultural minorities, individuals who live in rural 

communities) who rarely appear in large numbers in any one study. However, 

individual studies need to be conducted with some coordination (either explicit or 

implicit) so that they follow comparable assessment protocols; comparability is needed 

to allow for meaningful combinations of results or, more preferably, pooling of the data. 

These and other techniques may be helpful for understanding “for whom and under 

what circumstances,” but the problem of building models for these inquiries has not yet 

been completely solved. Clearly, NIMH needs to make more effort to develop and 

disseminate analytic methods to meet these goals.
77