PRIORITIES

 FOR PREVENTION RESEARCH

AT NIMH

A Report

by the 

National Advisory Mental Health Council 

 Workgroup on 

Mental Disorders Prevention Research

National Institutes of Health

National Institute of Mental Health

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ROSTER: NAMHC WORKGROUP ON 

MENTAL DISORDERS PREVENTION RESEARCH

 

Thomas J. Coates, Ph.D. (Chair)* Kathleen R. Merikangas, Ph.D.

Professor of Medicine and Epidemiology Professor of Epidemiology

Director, UCSF AIDS Research Institute and and Psychiatry

 Center for AIDS Prevention Director, Genetic Epidemiology

University of California, San Francisco, CA Research Unit

Mary Jane England, M.D.*# New Haven, CT

President

Washington Business Group on Health Judith G. Rabkin, Ph.D.

Washington, DC Professor of Clinical Psychology in Psychiatry

Brian R. Flay, D. Phil. and Surgeons 

Professor and Director New York State Psychiatric Institute, and 

Health Research and Policy Centers Adjunct Professor of Clinical Psychology in 

University of Illinois at Chicago Psychiatry

Chicago, IL Cornell University Medical College

Ellen Frank, Ph.D.* 

Professor of Psychiatry and Psychology Irwin N. Sandler, Ph.D.

Department of Psychiatry Professor and Director

School of Medicine Center for Preventive Intervention Research

University of Pittsburgh Arizona State University

Pittsburgh, PA Tempe, AZ 

Beatrix A. Hamburg, M.D. José Szapocznik, Ph.D.*

President Professor and Director

William T. Grant Foundation Center for Family Studies

New York, NY Department of Psychiatry

Dale L. Johnson, Ph.D.* University of Miami School of Medicine

Professor of Psychology Miami, FL

Department of Psychology

University of Houston Myrna M. Weissman, Ph.D.*

Houston, TX Professor of Psychiatry and Epidemiology

Robert L. Johnson, M.D.* and Surgeons and

Professor of Pediatrics Chief, Department of Clinical and Genetic

 and Clinical Psychiatry Epidemiology

Director of Adolescent Medicine New York State Psychiatric Institute

Department of Pediatrics New York, NY 

University of Medicine and Dentistry

of New Jersey Anne H. Rosenfeld (Executive Secretary)

Newark, NJ National Institute of Mental Health

Yale University

Columbia University College of Physicians

New York, NY 

 and Behavioral Sciences

Columbia University College of Physicians

Rockville, MD 

---------------

*Current NAMHC member

#Resigned 9/97

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April 1998 

Dear Dr. Hyman:

I am pleased to present to the National Advisory Mental Health Council (NAMHC) the final

report of the NAMHC Workgroup on Mental Disorders Prevention Research. The Workgroup 

reviewed the current NIMH prevention research portfolio, identified its gaps, and made selected

strategic recommendations about research directions in the near future. We did not, however,

undertake a complete reconceptualization of prevention research relevant to NIMH. That work

had already been done by the Institute of Medicine and by earlier NIMH advisory groups. Rather,

we started with the current de facto definition of prevention research and, at your request,

attempted to broaden its focus and scope. We recommend an expanded definition that includes

research on a broadened array of mental disorders and the prevention of comorbidities, relapse,

and disability, as well as preventive services research. The essence of our report is integration: 

across phases of prevention research (pre-intervention, intervention, and services); across

disciplines (biological, psychological, social); across levels of intervention (individual

psychological, social); across prevention and treatment research; and across disorders.

We examined carefully the scope and balance of research in the current NIMH portfolio and

found that it focused on a few disorders, and then only on a few approaches toward their

prevention. Prevention research has had a promising beginning, and risk-factor, risk process, and

intervention research have all been productive in some areas. But much more can and should be

done. Our recommendations provide strategic directions for pre-intervention, intervention, and

services research.

The recent reorganization of NIMH holds considerable promise for prevention research, but the

Workgroup is concerned that the integration required to move the field forward might be lost. 

Therefore, we recommend ongoing mechanisms to ensure leadership and continuity in prevention

research, including continuing the Prevention Research Consortium, convening a newly

constituted standing Prevention Research Advisory Group, and providing leadership in crossinstitute and cross-agency coordination. Our work is not done. We propose that it be carried

forward in a series of summit meetings that will summarize the state of knowledge about risk and

protective factors and processes as well as intervention strategies for specific disorders. These

meetings should also encourage a unified view within the field of prevention, and bring together a

variety of prevention investigators across mental and other chronic disorders, substance abuse

disorders, and infectious diseases.

We thank you for this opportunity and hope that our report is helpful.

Sincerely,

Thomas J, Coates, Ph.D., Chair

NAMHC Workgroup on Mental Disorders Prevention Research 

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Acknowledgments

We wish to thank the following individuals and organizations for sharing their time and

expertise with the Workgroup:

NIMH Staff:

Stephen Foote, Ph.D.

Ellen Gerrity, Ph.D.

John Hsiao, M.D.

Peter Jensen, M.D.

Doreen Koretz, Ph.D.

Victoria Levin, M.S.W.

Susan Matthews

Katherine Magruder, Ph.D., M.P.H.

Ann Maney, Ph.D.

Eve Mo cicki, Sc.D., M.P.H.

William Narrow, M.D., M.P.H.

Grayson Norquist, M.D., M.S.P.H.

Mary Ellen Oliveri, Ph.D.

Jane Pearson, Ph.D.

Willo Pequegnat, Ph.D.

Julie Phillips

Juan Ramos, Ph.D.

Matthew Rudorfer, M.D.

Karen Shangraw

Jane Steinberg, Ph.D.

Ellen Stover, Ph.D.

Richard Weise, Ph.D.

Steven Zalcman, M.D.

as well as members of the NIMH Prevention Research Consortium

Contract Support Staff:

Ms.Gwendolyn Brighthaupt, B.L. Seamon & Associates

Mr. Chanda Chhay, Caset Associates, Ltd. 

Ms. Diane Hinkly

Organizational Statements:

Alzheimer’s Association

American Academy of Child and Adolescent Psychiatry

American Psychiatric Association

American Psychological Association

Clinical Social Work Federation

Consortium of Social Science Associations

Mental Health Association of Southeastern Pennsylvania

National Alliance for the Mentally Ill

National Mental Health Association

National Prevention Coalition

Society for Prevention Research

World Federation for Mental Health

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CONTENTS 

EXECUTIVE SUMMARY .................................................................. 7

I. INTRODUCTION ..................................................................... 12

Background .................................................................... 12

Workgroup Charge and Composition ................................................ 15

II. A FRAMEWORK FOR 

MODERN PREVENTION SCIENCE ................................................. 16

Recommendation 1: Adopt an Expanded Definition of Prevention Research ................ 23

III. WORKGROUP METHODS AND KEY FINDINGS ......................................... 27

Workgroup Methods ............................................................. 27

Key Findings ................................................................... 28

Pre-Intervention Research ................................................. 28

Preventive Intervention Research ............................................ 29

Preventive Services Research .............................................. 31

IV. MAJOR RESEARCH INITIATIVES RECOMMENDED ...................................... 32

Recommendation 2: Strengthen Epidemiologic Foundations of Prevention Research ....... 32

Recommendation 3: Stimulate Pre-Intervention and Intervention Studies of 

Early Childhood Risks for Adverse Developmental Outcomes ....... 33

Recommendation 4: Expand Research on Depression and Anxiety Across the Life Span .... 34

Recommendation 5: Refine and Advance the Empirical Basis for Conduct Disorder

 Prevention Research ....................................... 35

Recommendation 6: Broaden Disorders and Populations Targeted for Prevention Research . 36

Recommendation 7: Expand Studies on Comorbidity Prevention ........................ 38

Recommendation 8: Develop a Program of Preventive Services Research,

 Including Prevention Policy Research .......................... 39

Recommendation 9: Encourage and Support Long-Term Followup in Prevention Research . . 41

Recommendation 10: Build Prevention Research Capacity, 

Especially through Training Grants ............................. 41

V. RECOMMENDATIONS FOR NIMH LEADERSHIP AND CONTINUITY

 IN PREVENTION RESEARCH ACTIVITIES .......................................... 44

Context: Reorganization of NIMH and Grant Review Process ............................ 44

Recommendation 11: Provide Scientific Leadership for Prevention Research .............. 44

Recommendation 12: Provide Leadership in Prevention Grant Review ................... 47

Recommendation 13: Provide Leadership for Cross-Institute and Cross-Agency Linkages ... 48

Recommendation 14: Provide Leadership in Prevention Research Dissemination ......... 48

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CONTENTS (cont.)

APPENDIX A: Charge: NAMHC Workgroup on 

Mental Disorders Prevention Research .............................................. 50

APPENDIX B: Roster: National Advisory Mental Health Council ................................ 52

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EXECUTIVE SUMMARY

The Workgroup on Mental Disorders Prevention Research of the National Advisory

Mental Health Council (NAMHC) was charged by the Director of the National Institute

of Mental Health (NIMH) to examine the NIMH research portfolio on the prevention of

mental disorders, identify research gaps and opportunities, and indicate priorities for

future research on prevention.

The Workgroup believes that the field is ready to initiate a third generation of

prevention research building on prior research accomplishments and integrating these

with advances in the biomedical, behavioral, and cognitive sciences. The Workgroup’s

14 recommendations are intended to pave the way for this important next step.

A Framework for Modern Prevention Science

> Recommendation 1: Adopt an Expanded Definition of Prevention Research

The Workgroup recommends the adoption of a broadened definition of prevention

research that (a) expands pre-intervention research beyond traditional risk factors by

including research that can encompass basic biological, psychological, and

sociocultural risk factors; (b) includes the prevention of relapse, co-occurring illnesses,

disability, and the consequences of severe mental illness for families; and (c)

emphasizes the critical importance of integration across pre-intervention, preventive

intervention, and preventive services research.

Other principles guiding modern prevention science include the importance of:

o a developmental perspective across the life span;

o multiple, interacting causal factors;

o drawing on multiple disciplines in conceptualizing prevention;

 o systematic and rapid translation of research from basic risk-factor studies to

real-life applications in clinical and community settings;

o a broad range of intervention approaches, including pharmacologic, 

psychological, family, social system, and public policy changes;

o public health need and scientific opportunity as the driving forces;

o preventing comorbidity, especially between mental disorders and substance

abuse;

o preventing relapse, disability, and other consequences of mental illness;

 o testing both the safety and efficacy of preventive interventions. 

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Selective interventions are targeted to individuals or groups with a higher-than-average risk of 1

developing mental disorders; indicated interventions are targeted to people with minimal but detectable

mental illness signs or symptoms who do not have a diagnosable disorder.

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Gaps and Opportunities

The Workgroup reviewed and analyzed the FY 1996 NIMH prevention research

portfolio. All prevention grant abstracts judged by NIMH staff as relevant to preintervention, intervention, and services research were reviewed and were characterized

by topic area, target group populations, age and type of research subjects, disorders or

conditions, and methods. Based on this work, key gaps and opportunities in prevention

research were identified. 

Gaps in pre-intervention research

o Data are insufficient from population-based, prospective cohort, high-risk, and

family studies to provide an empirical basis for choosing the timing and target

groups for prevention strategies, particularly those using a selective or indicated

approach.1

 

o The risk-factor research portfolio is unevenly balanced with respect to both the

public health significance and the severity of particular target outcomes. 

o The amount of risk-factor research focused on specific population subgroups

(e.g., specific combinations of cultures, genders, and/or developmental stages) is 

very limited. 

o Little interdisciplinary collaboration exists within and among key domains of riskfactor research relevant to prevention. 

o Dramatic advances have been made in knowledge about the role of genetic and

biologic risk factors for mental disorders. However, little systematic research has

explored the interaction of these factors with psychological and environmental

factors or the potential translation of knowledge about these risk factors into applied

prevention research. Nor has it explored the diverse impacts--positive and negative-

-expected from such programs.

Gaps in preventive intervention research

o Many treatment and intervention studies currently in the NIMH portfolio have

strong relevance for prevention but are not characterized as such and are not

included in planning for prevention. 

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o Studies on relapse prevention and comorbidity prevention are not currently

included in planning prevention research at the indicated level or beyond. 

o Scientific initiatives to advance each level of intervention and bridge across levels

have not been systematically identified.

o Preventive intervention in the research portfolio has tended to focus on a limited

number of disorders, such as depression and conduct disorder, while relatively less

attention has been paid to development of interventions to prevent other mental

disorders, such as anxiety disorders, and their comorbidities.

o Preventive intervention strategies have primarily focused on individual-level

processes rather than the broader context in which they occur, (e.g., family, school,

and community). 

o Research is lacking on methods of collaborating with communities to develop

prevention trials and to encourage their adoption of well-evaluated prevention

programs once the research is completed.

o Despite the rapid development of knowledge about mechanisms of early cognitive

development, very few preventive trials focus on intervening during prenatal or early

infancy periods, when malleability may be high. 

o Few research interventions to prevent recurrence or co-occurring illness focus on

children or adolescents, despite considerable evidence of the recurrent nature of

many mental disorders and the accretion of co-occurring disorders across childhood

and adolescence.

o There is a lack of systematic attention to significant variation in the effects of

preventive interventions related to cultures, genders, and life stages.

Gaps in preventive services research

In the area of mental health services research (characterized as organization and

financing studies, clinical services studies examining effectiveness issues, and

dissemination research), virtually no preventive services research of any kind was

found under NIMH sponsorship. In addition, the following gaps related to

preventive services research were identified:

o There are few scientists in the prevention field with training in health economics. 

This background is critical for adequate evaluation of the costs and benefits of

preventive intervention programs.

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o While there is substantial effort to identify the cost-effectiveness of treatment and

other services, there has been little translation of cost-benefit analyses to prevention

of relapse, comorbidity, and long-term care.

o Basic data are scant on the cost and impact of mental disorders compared with

other chronic disorders. 

Major Research Initiatives

The Workgroup recommended nine major research initiatives based on its assessment

of the current NIMH research portfolio, scientific opportunity, and public health need:

> Rec. 2: Strengthen the epidemiologic foundations of prevention research. 

> Rec. 3: Stimulate pre-intervention and intervention studies of early childhood

risks for mental disorders and other adverse developmental outcomes. 

> Rec. 4: Expand research on the prevention of depression and anxiety across 

the life span.

> Rec. 5: Refine and advance the empirical basis for conduct disorder

prevention research

> Rec. 6. Broaden disorders and populations targeted for prevention research. 

> Rec. 7: Expand studies on comorbidity prevention.

> Rec. 8: Develop a program of preventive services research, including

prevention policy research.

> Rec. 9: Encourage and support long-term followup in prevention research.

> Rec. 10: Build prevention research capacity, especially through training

grants.

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Leadership and Continuity in Prevention Research Activities 

The reorganization of NIMH presents an opportunity and several challenges for

prevention research. The Workgroup was concerned that the reorganization might

divide and diffuse responsibility for identifying new scientific opportunities and

encouraging the systematic transformation of promising leads into practical prevention

interventions. To remedy this, the Workgroup developed the following

recommendations:

> Rec. 11: Provide scientific leadership for prevention research by continuing

the NIMH staff’s Prevention Research Consortium and convening a newly

constituted standing Prevention Research Advisory Group (PRAG), which

represents expertise in epidemiology, developmental psychopathology,

methodology, and the conduct of community-based prevention trials

> Rec. 12: Provide leadership in prevention grant review to ensure that experts

in epidemiology, developmental psychopathology, methodology, and the

conduct of community-based prevention trials are involved in review.

> Rec. 13: Provide leadership for cross-agency linkages between NIMH

prevention efforts and the Department of Education, as well as linkages with

other components of the National Institutes of Health (e.g., NIDA, NIAAA, and

NICHD).

> Rec. 14: Provide leadership for prevention research dissemination.

Unfinished Business

Charting a new course for NIMH prevention research is an ongoing process. To

provide continuing impetus for NIMH prevention research, the Workgroup recommends

that the Prevention Research Advisory Group collaborate with the Prevention Research

Consortium to plan and execute in the next year a series of Prevention Research

Summits to summarize the state of knowledge about risk and protective factors and

processes, preventive interventions, and prevention research for each major mental

disorder, as well as common risk and protective factors across disorders. The Summits

should recommend to the NAMHC the highest research priorities across disorders and

phases of research, based on public health need and scientific opportunity. There is

also great potential to stimulate cross-fertilization among researchers studying mental

disorders, other chronic illnesses, and infectious diseases, and to integrate across a

wide range of intervention technologies, including biological, behavioral,

organizational, community- and policy-based approaches.

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I. INTRODUCTION

Background 

Prevention research has become an important new frontier in the study of mental

disorders. The public health toll of mental disorders is becoming more widely

recognized: Depression is the fourth leading cause of illness-related disability in the

world, and schizophrenia and other psychotic disorders are among the most debilitating

and persistent diseases. Rapid advances in the basic biological, psychological, and

social sciences have provided unprecedented scientific opportunities to understand

and prevent these and other mental disorders These developments close the last

substantial gap in the recognition that mental disorders are to be investigated,

understood, treated, and prevented essentially as are all other medical illnesses. This

new confluence of mental and medical health research is of mutual benefit. Across

both fields and at all levels of research there is increasing appreciation of the

importance of interdisciplinary approaches and the value of including and integrating

contributions from behavioral and social science research, along with findings from

molecular biology, genetics, biomedicine, and biotechnology.

Over the last 50 years, with the spectacular advances in medical treatments facilitated

by modern scientific research, the burden of medical illness has largely shifted from

acute and curable infections to complex chronic diseases that lack definitive cures,

some of which stem from unhealthful life styles. These latter diseases include some of

the leading causes of death, such as heart disease and lung cancer. There has also

been enormous progress in identifying the role of genetic, biologic, social, and

behavioral risk factors and their interaction in the etiology of these chronic diseases. 

The newly emerging infectious diseases, such as AIDS, as well as the threat of drug

resistant re-emerging infectious diseases, such as tuberculosis, also have been shown

to have major behavioral components. 

Given the current burden of mental and medical illness, in which suffering, disability,

and death are prominent and few definitive cures exist, a heightened focus on

prevention is essential. For many physical diseases a high priority is being given to

rigorous programs of prevention research. It is time for prevention research on mental

disorders to assume similar prominence.

Building on two generations of prevention efforts in the mental health field, this is an

opportune moment for NIMH to launch a new era of prevention activities as an integral

part of its research program. Advances in scientific knowledge, research paradigms,

concepts, and a range of new methods now offer great promise for a third generation of

prevention intervention--one that is scientifically sophisticated and addressed to a

broadened range of troubling and largely neglected areas of mental disorder. 

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The first generation of efforts to prevent mental disorder began in the 1930s when, as

an outgrowth of the turn-of-the-century mental hygiene movement, the focus gradually

expanded beyond ameliorating the plight of those in asylums to include the prevention

of many forms of social and emotional maladjustment. The new goal was to assure the

well-being and “positive mental health” of the general population through primaryprevention interventions aimed at creating health-promoting environments for all.

These efforts were based on humanitarian concern, but had few, if any, research

underpinnings.

The second generation of interventions to prevent mental disorder, which began in the

late 1960s, reflected the impact of a growing health and mental health research

knowledge base. Some scientists retained their broad-based emphasis on primary

prevention, while others began to target specific “at-risk” groups for study and

intervention. During the 1960s there had been a burgeoning of research on the

causes, mechanisms, and effects of stress on bodily and mental functioning. “At-risk”

persons were defined as those who would predictably experience periods of substantial

life stress, such as domestic violence, divorce, bereavement, or unemployment as

precursors of mental distress or disorder. Changing behavior for health also became

an active area of study and prevention during the same period. Those studies placed a

strong emphasis on preventing lung cancer and heart disease through programs to

prevent or reduce smoking, obesity, high cholesterol intake, and sedentary life styles. 

Despite the strengthened scientific foundations for prevention, both in research and in

preventive services delivery, the mental health field’s capabilities lagged behind the

public health need. 

In 1978, the second-generation prevention efforts were characterized by the

President’s Commission on Mental Health (PCMH) as, “... unfocused and

uncoordinated.” In response, the PCMH recommended that, as a first step, “...A Center

for Prevention” should be established at NIMH, with primary prevention as its major

activity. The PCMH mandate under which the NIMH Prevention Center was

established further noted that programs sponsored by the Center “... should be aimed

at high-risk populations and high-risk situations limited to strategies where prospects

for successful intervention are greatest.” The PCMH also suggested giving priority to

programs for children. The NIMH Center for Prevention Research and its programmatic

successors continued to function under this mandate for nearly 20 years, promoting

considerable progress in building the scientific foundation of an interdisciplinary field of

prevention research in areas of epidemiology, human development, and intervention

research methodology.

Scientifically rigorous studies are now yielding promising evidence of the efficacy of

preventive interventions. Recent meta-analytic reviews of preventive interventions

support the efficacy of many approaches to prevention, while pointing to significant

gaps and future directions for research. Findings from individual experimental trials

illustrate the potential power of a number of preventive approaches. For example,

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long-term evaluations of experimental trials of home-visitation programs with high-risk

mothers and infants have provided evidence that such programs are effective in

reducing antisocial behavior problems. One 15-year followup of a randomized trial of a

home-visitation program found that the high-risk mothers in the program had

significantly fewer verified reports of child abuse and neglect, fewer arrests for criminal

behavior, less impaired behavior from alcohol or drug abuse, and fewer subsequent

pregnancies--all of which are risk factors for children’s development of conduct

problems. 

Programs that provide brief training in social cognitive skills to pre-adolescents with

high levels of depressive symptoms have successfully reduced their rates of such

symptoms over a 2-year followup. Experimental trials have also shown the efficacy of

preventive interventions with populations undergoing stressful life transitions. For

example, a structured job-search intervention with the recently unemployed significantly

reduced the incidence of severe levels of depressive symptoms over a 2 1⁄2-year

followup. 

Despite the promise of a number of prevention trials, much work is needed to achieve a

scientifically grounded knowledge base that can aid in reducing the incidence and

prevalence of mental disorders in the foreseeable future. A continuing awareness of

the intriguing but still largely unfulfilled promise of prevention research on mental

disorders stimulated the creation in 1985 of a congressionally mandated Office of

Prevention within NIMH, as well as several recent assessments of this second

generation of prevention research. Two reviews have been particularly influential: 

Reducing Risks for Mental Disorders: Frontiers for Prevention Intervention Research,

the 1994 report of the Institute of Medicine (IOM), and A Plan for Prevention Research

for the National Institute of Mental Health, the 1996 report to the NAMHC by the NIMH

Ad Hoc Committee on Prevention Research. The latter report incorporated

recommendations from the IOM report and from the 1993 NIMH report, The Prevention

of Mental Disorders: A National Research Agenda by the NIMH Prevention Research

Steering Committee. Although the current report is based upon a broader definition

and scope of prevention research than those that preceded it, the Workgroup is

indebted to those prior efforts, which have formed its conceptual foundation.

A third generation of prevention activity is now proposed. The field is ready to build on

prior prevention research accomplishments and integrate these with advances in the

biomedical, behavioral, and cognitive sciences. These basic science findings can form

the foundation for understanding more precisely the origins of the full spectrum of major

mental disorders and for identifying their risk and buffering factors. These findings can

be translated into preventive intervention strategies that can be tested and, if

efficacious, disseminated. The field is also ready to expand the prevention terrain to

include a broader array of major mental illnesses, and to include a focus on preventing

relapse, disability, and the comorbid conditions prominently associated with mental

disorders, as well as preventing the incidence of disorders. In this next generation,

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scientifically based preventive strategies will, at last, have significant impact on the

public’s mental health.

Workgroup Charge and Composition

The NAMHC Workgroup on Mental Disorders Prevention Research was charged with

examining the NIMH research portfolio on the prevention of mental disorders,

identifying research gaps and opportunities, and indicating priorities for future research 

(see Workgroup Charge, Appendix A). In that charge, NIMH Director Dr. Steven

Hyman noted that at least two major issues gave rise to the Workgroup’s creation:

“recognition of the value of the prevention research perspective (including its

developmental approach and its focus on nonclinical as well as clinical settings); and a

growing realization that severe mental disorders, which are now underrepresented in

the NIMH prevention research portfolio, are not likely to be amenable to primary

prevention interventions with our current knowledge base.”

The Workgroup, led by Dr. Thomas Coates, consisted of NAMHC members as well as

ad hoc participants. The 12 appointed members included researchers with experience

in prevention research in areas of mental disorders, substance abuse, and AIDS. Their

disciplines spanned public health, psychology, child and adult psychiatry, pediatrics,

and epidemiology. Through their participation in earlier efforts to assess NIMH

prevention research, two of the members provided an important link with past reports

on prevention research.

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 II. A FRAMEWORK FOR 

MODERN PREVENTION SCIENCE

During the course of the Workgroup’s deliberations, a number of implicit but shared

assumptions about a broad and integrated prevention research field became explicit. 

Together, these guiding principles, stated below, provide the framework underpinning

both the Workgroup’s assessment of the current state of NIMH prevention research and

its choice of initiatives to advance the field. 

A. For research planning purposes, any definition of prevention research must

encompass the full spectrum of relevant research across three major domains. 

The first issue examined by the Workgroup was the definition of prevention research

relevant to mental disorders. It was soon apparent that prevention research in the

mental health field has no universally accepted definition, although two public health

concepts are widely used within the prevention research community: the traditional

public health distinctions of primary, secondary and tertiary prevention, as well as

Gordon’s (1987) characterization of preventive interventions as universal, selective,

and indicated. There has been a tendency to regard primary prevention (i.e.,

intervention before the onset of symptoms) as the only true form of prevention. 

However, this perspective fails to recognize the mental health field’s need for effective

prevention approaches both before and after symptoms become apparent.

 The 1994 Institute of Medicine report and the 1996 prevention report to NAMHC based

on it adopted a definition of prevention that adapted Gordon’s terms as follows:

 

“Universal preventive interventions for mental disorders are targeted to the general

public or a whole population group that has not been identified on the basis of

universal risk.

Selective preventive interventions are targeted to individuals or a sub-group of the

population whose risk of developing mental disorders is significantly higher than

average. The risk may be imminent, or it may be a lifetime risk.

Indicated preventive interventions are targeted to high-risk individuals who are

identified as having minimal but detectable signs or symptoms foreshadowing mental

disorder, or biological markers indicating predisposition for the mental disorder, but

who do not meet DSM-III-R diagnostic levels at the current time.”

The definition excluded all individuals with full-blown disorders. It also excluded the

domain of pre-intervention research (defined on the next page) because it was focused

solely on preventive interventions. 

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 The Consortium, initially co-led by Dr. Eve Mo cicki, formerly Chief of the Prevention and 2

Behavioral Medicine Research Branch, and Dr. Juan Ramos, Associate Director for Prevention, was

created in late 1996 in response to recommendations in the 1996 NAMHC report on prevention research.

17

A concern with the narrowness of current prevention definitions led Dr. Hyman to ask

the Workgroup to consider “expanding the domain of NIMH prevention research

beyond ‘primary prevention’ to include: a) the early identification of symptoms in a

variety of mental disorders as a basis for early intervention and the prevention of

possible comorbidity (e.g., alcoholism as a complication of social phobia) or

complication (e.g., agoraphobia as a result of panic disorder); and b) the use of

interdisciplinary (including both pharmacologic and behavioral) approaches in relapse

prevention in mental disorders with recurrent or worsening courses.”

The task of developing a new NIMH prevention research definition consonant with this

broadened perspective was assigned to the NIMH Prevention Research Consortium,2

an internal NIMH body consisting of representatives from all NIMH research programs

germane to prevention research. The Workgroup used successive refinements of the

Consortium’s definition to guide the classification and analysis of NIMH prevention

research portfolio. The Workgroup has enthusiastically adopted the Consortium’s

definition of the domain of prevention (with some small changes), as presented below: 

A major mission of the National Institute of Mental Health (NIMH) is to conduct

and support research to improve mental health and prevent mental disorders,

behaviors symptomatic of disorder, and related consequences, including

research on the prevention of HIV transmission and the consequences of HIV

infection and AIDS. An underlying assumption of NIMH prevention research is

that human behavior is subject to biological and environmental influences that

affect the course of human development. Prevention research can be broadly

characterized as seeking to understand and influence the developmental

trajectory from the earliest formation of the nervous system throughout the

course of life in order to prevent mental disorders and promote mental health.

Advances in prevention research result from an interactive process among

three domains: pre-intervention research, preventive intervention research,

and preventive service systems research.

Pre-intervention research involves basic social, behavioral, and

biological, pre-clinical, clinical, and epidemiologic/public health studies that

form the building blocks for preventive intervention research . This includes

research on risk and protective factors and risk and protective processes to (1)

identify basic mechanisms of biological, behavioral, and psychological

change; (2) elucidate factors that increase or decrease the likelihood of

developing target outcomes; (3) develop and test models of processes that

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mediate and moderate the translation of risk into disorder, its course, and its

consequences. Pre-intervention research also includes translating results

from the preceding three areas into (4) intervention development research

aimed at a) promoting research methods innovation and development, and b)

designing, pilot testing, refining, and analyzing new preventive intervention

strategies prior to testing in efficacy trials. The focus in pre-intervention

research may range from individual-level outcomes to population-level

outcomes, as in epidemiologic and other public health research.

Preventive intervention research is the core of prevention research because of

its great potential for directly improving public health. It consists of preventive

intervention efficacy and effectiveness trials involving participants who (1)

have no current symptoms of mental disorder and were never symptomatic; (2)

have current sub-clinical symptoms; (3) have a currently diagnosed disorder

and/or were previously symptomatic--for them the emphasis is on prevention

of relapse or recurrence; or (4) have a currently diagnosed disorder, with the

emphasis on prevention of comorbidity or disability. The choice of prevention

targets will depend on scientific opportunity, pre-intervention knowledge base,

and the public health burden of the disorder to be prevented.

Efficacy trials test the extent to which a specific intervention produces 

positive results under near-ideal conditions. Effectiveness trials test the

extent to which efficacious interventions have a beneficial effect when

deployed in natural settings . Such trials usually are designed to test the

generalizability of intervention effects for a defined population or service

setting. Effectiveness trials may also include economic analyses, such as

cost-benefit analyses; this research forms the bridge to preventive service

systems research. Both efficacy and effectiveness studies can involve

randomized, controlled trials, and both can focus on individual-level or on

population-level outcomes in some community-based trials.

Preventive intervention research may target interventions based on risk and

protective factors and processes unique to particular disorders as well as

those common to a variety of outcomes. The interventions may be delivered

through a variety of service system sectors, including the general health sector

(e.g., primary care, health maintenance organizations), the specialty mental

health sector, or through schools or other community settings and types of

organizations. Preventive interventions may be delivered independently of

other services, or as part of a package of services (e.g., preventively focused

parenting interventions delivered in conjunction with pharmacologic and/or

psychosocial treatment of parental depression). Research on preventive

interventions may target individuals and/or broader levels of the social

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environment, such as families, work or school settings, communities, and their

social norms and policies.

Preventive service systems research is concerned with the study of effective

preventive interventions within service systems . The focus of studies in this

category is on the interactive effects of preventive interventions with

organizational aspects of the service environment, such as system structures,

including characteristics and skills of those providing care and of the

populations being served, organizational culture and climate, and methods of

financing services.

Preventive service systems research can include (1) studies of policies and

procedures that facilitate or hinder the adoption and implementation of

effective interventions, and research on the technology of effective

dissemination; (2) studies of the effects of age, gender, ethnicity, or

sociocultural factors that affect access to or use of available preventive

interventions; and (3) studies of the costs associated with delivery of

preventive interventions, as well as methods of financing such interventions. 

The focus of preventive service systems research is on contextual and systemlevel outcomes.

A diagram of the prevention research cycle described above, including the types of

research and target populations, is presented in Figure 1. (available at

http://www.nimh.nih.gov/research/prevfg1.htm) This expanded definition of prevention

research reflects and reinforces the interdisciplinary nature of this research area,

spanning genetics and neuroscience, psychology, psychiatry, clinical research,

services research, and epidemiology. Figure 2. (available at

http://www.nimh.nih.gov/research/prevfg2.htm) illustrates how interventions with each

targeted population contribute to the common objective of reducing rates of disorder in

the total population. Figure 3. (available at

http://www.nimh.nih.gov/research/prevfg3.htm) shows the changing conceptual

boundaries of prevention research across generations of prevention intervention.

The scientific opportunity presented by the expanded definition of prevention is that

each type of prevention can make unique and complementary contributions to the

overall public health goal of reducing rates of disorder in the population. Each of these

strategies can reach different segments of the population with intervention strategies

that are appropriately targeted at malleable risk and protective factors. Universal,

selective, and indicated prevention strategies are needed to reach broad segments of

the population at critical developmental periods in order to reduce the incidence of

disorder. Despite these efforts, however, many people will still experience disorder,

and prevention strategies are critically needed to prevent relapse and comorbid

conditions as part of comprehensive treatment approaches. The Workgroup strongly

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Although the term “developmental” often refers solely to child development, it is used here to 3

indicate developmental stages across the life span.

20

endorses a vigorous scientific research agenda on this full array of strategies--

universal, selective, indicated, relapse and comorbidity prevention

--to reduce rates of mental disorder in the population.

The Workgroup believes that this definition encompasses a vision of prevention

research that should be shared by all relevant NIMH programs. Therefore, the

Workgroup’s first recommendation is the following: 

Recommendation 1: Adopt an Expanded Definition of Prevention Research

o NIMH should adopt formally the expanded definition of prevention research 

developed by the NIMH Prevention Research Consortium, with the following

conceptual implications for NIMH-sponsored research: a) expand preprevention or risk-factor research to include etiologic research that

encompasses basic biological, psychological, and sociocultural factors as

well as multiple interactive influences on behavior and its context; b) extend

preventive intervention and service-level research to include prevention of

relapse, comorbidity, disability, and the consequences of severe mental

illness for families; and c) emphasize the critical importance of integration

across pre-intervention, preventive intervention, and preventive services

research. 

It is important to note that the new conceptualization of prevention represents an

expansion of the prevention research agenda; it does not represent a decreased

commitment to preventing mental disorders in people currently without

symptoms or those who have never been mentally ill. 

B. A developmental perspective is a key component of prevention research . 

Research based on a developmental. perspective has yielded significant new insights 3

into the paths, continuities, and changes in normal and pathological processes over the

life span The development and life course of mental disorder result from a complex

interplay of biological and psychological processes as individuals interact with their

changing environments. Prevention research must take into account these dynamic

forces and the developmental trajectories to which they lead. These developmental

processes need also to be viewed within an epidemiologic framework to understand

how they affect incidence and prevalence of mental disorder in the population for

different age groups.

 

Prevention research has already benefited from insights about the significance of

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predictable, normal developmental transitions (e.g., school transitions, puberty,

retirement) as points of vulnerability and/or growth opportunity. The developmental

consequences of non-normative life crises (e.g., divorce, job loss, bereavement,

serious injury or illness) and the factors that protect against their potentially adverse

effects on mental health are being studied as well. Findings from such studies are

beginning to clarify the origins and timing of the onset of disorders, as well as strategic

developmental points for intervention.

Because this body of knowledge is fundamental for research on prevention, it is

essential to support longitudinal studies that can use both prospective long-term

designs and strategic life-course data collection to track both lifetime developmental

processes and the duration of intervention programs’ intended and unintended effects. 

 

C. Understanding the development of mental disorder requires knowledge of the

influence of multiple interacting causal factors or processes rather than focus on

a single causal agent . Some factors have a pathological influence and are associated

with an increased risk for disorder, while others have a positive or protective influence

and are associated with a decreased risk. Risk and protective factors include all levels

of analysis--biological, psychological, and environmental. These factors may be

uniquely associated with specific disorders. However, some may be common across a

range of disorders, and these deserve special emphasis. 

D. A complete prevention research program must encourage the systematic

translation of research knowledge from basic risk-factor studies to real-life

applications in clinical and community settings. NIMH-sponsored prevention

research should contribute to the systematic growth and effective application of

empirical knowledge in all of the following areas of investigation: a) using findings from

basic laboratory studies and rigorous clinical and epidemiologic studies (risk and

protective factors must be identified and empirically validated as a basis for selecting

populations for preventive interventions by determining which risk processes have the

greatest promise as potentially malleable and powerful points of intervention); b) 

demonstrating in field trials that particular preventive interventions are effective and

documenting their cost-effectiveness; c) revealing and overcoming barriers to the

dissemination and adoption of cost-effective interventions; and d) identifying the

characteristics of prevention service systems best suited for wider dissemination and

adoption.

E. A broad range of potential preventive intervention approaches needs to be

explored, including pharmacological, psychological, family process, and social

system and policy changes. Preventive interventions can include all levels of

approaches to producing change. Intervention approaches should be selected for their

efficacy in changing processes involved in the development and recurrence of disorder

and for the feasibility of delivering them in specific targeted populations. Often, the

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combination of multiple approaches is needed to produce the desired preventive effect

in a given population.

F. Public health need and scientific opportunity should be the key criteria

guiding the allocation of research resources in NIMH, a research component of

the Public Health Service. In prevention research, scientific priorities should be

commensurate with the severity and prevalence of the disorders of interest, with priority

given to those disorders that are both severe and relatively widespread, resulting in a

heavy burden of illness on the population. Of equal importance is the criterion of

scientific opportunity. Research resources in mental health should be primarily

allocated where they can build upon emerging concepts, methods, or technologies that

will significantly advance existing knowledge or open up promising new areas of

investigation. 

G. Prevention of mental disorders should include a focus on preventing

conditions that are often comorbid with mental disorders, particularly substance

abuse and physical illness. An Institute focus on discrete mental disorders should

not preclude studies of common underlying risk factors that may contribute to multiple

adverse outcomes. Studies of the effects of preventive interventions should include

their impact on the burden of suffering from mental disorders and from co-occurring

conditions. 

H. Preventive intervention research should not simply be directed toward the

prevention of a first episode, but must also include prevention of repeated

subsequent episodes. Most mental disorders are relapsing or recurring in nature,

and their personal and financial costs can be largely attributed to episodes that follow a

first onset. Therefore, prevention of recurrence and relapse--including relapse after

successful treatment--is an essential aspect of a public health strategy to reduce

prevalence.

I. The contributions and collaborations of multiple disciplines are essential for

scientific advances in prevention research. Prevention research requires the

contributions and interactions of researchers from a broad range of disciplines,

including psychiatry, psychology, social work, nursing, epidemiology, economics

genetics, and neuroscience, as well as sophisticated biostatistical and methodological

expertise. This disciplinary diversity is especially important for understanding the

development of mental disorders and accounting for the differential interactions and

impacts of biologic processes and environmental influences, whether at the molecular

or social ecological level. Prevention research studies need to integrate basic science

(e.g., genetics and neuroscience) with behavioral and social science to explain

complex phenomena such as why some mental disorders tend to aggregate in certain

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families and not others who seem to be similar, and to facilitate translation of basic riskfactor research into prevention and treatment programs. In the next generation of

prevention research, research in basic neuroscience, neuroimaging, neuroimmunology,

pharmacology, cognitive psychology, and genetics will need to be integrated with

epidemiologic, social, and psychological research on risk and protective factors for

mental disorders in adults and children across diverse U.S. subcultures. 

J. Both the safety and efficacy of preventive interventions should be tested. 

Outcome domains measured should include those in which positive outcomes are

expected as well as those in which negative, unintended effects might occur. This is

equally important for psychopharmacologic and psychosocial interventions. For both,

significant age, gender, and sociocultural factors may alter expected outcomes. 

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The research portfolio of the NIMH Office on AIDS, which had undergone several recent scientific 4

and administrative reviews, was exempted from the Workgroup’s review. 

24

III. WORKGROUP METHODS AND KEY FINDINGS

Workgroup Methods

To carry out its charge, the Workgroup held eight formal meetings between January

1997 and January 1998, and invited presentations by representatives of all NIMH

extramural research programs and by organizations with a particular interest in NIMH

prevention research (see Acknowledgments). The Workgroup examined abstracts of

the entire FY96 NIMH extramural research portfolio (excluding AIDS ) to identify the 4

scope and balance of prevention research across Institute programs. In addition,

interviews with NIMH program staff, and review of seminal books and papers helped to

frame the Workgroup’s deliberations in a context of scientific, professional, and

consumer concerns. 

The review and analysis of the FY 96 NIMH prevention research portfolio have been

central to the Workgroup’s deliberations. Rather than relying on pre-existing

categorizations, the Workgroup asked leaders of all NIMH extramural research

programs to code all their paid FY 96 grants as: 1) risk-factor research; 2) preventive

intervention research; 3) preventive services research; or 4) not relevant to prevention. 

This coding was based upon the working definition of prevention developed by the

NIMH Prevention Research Consortium. 

The Workgroup members were then divided into three subcommittees corresponding to

the three prevention research categories mentioned above (i.e., risk, intervention,

services). They examined all grant abstracts in their topic area--across all NIMH

research programs (except AIDS)--as well as examples of outstanding prevention

research selected by NIMH program staff. The Workgroup subcommittees

characterized grants in their topic areas by their target-group populations (e.g.,

universal, selective, indicated), by the age and type of research subjects, by disorders

(or conditions) actually or potentially being targeted for prevention, by research

methodology, and by other categories specific to their research domains (e.g., for the

intervention subcommittee, by type of intervention). This analytic matrix provided a

useful basis for describing broad patterns of research design and content-area

emphasis within the NIMH prevention research grant program of FY 96. 

However, the constraints of reviewing NIMH abstracts rather than full proposals

precluded a rigorous scientific assessment of the quality of NIMH-supported prevention

research. Also, resource constraints precluded a review of the current state of relevant

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basic bioscientific research knowledge that might inform or invite preventive

interventions for mental disorders. These constraints also precluded a systematic

examination of the relation between the NIMH prevention research program and

relevant studies being supported by other public and private funders. 

It should also be noted that the organizational structure of NIMH underwent major

changes between January 1997, when the Workgroup first convened, and January

1998, when the Workgroup held its final meeting. While developing its

recommendations, the Workgroup attempted to keep abreast of these changes and to

take into account their potential impact on the Institute’s prevention research program. 

The Workgroup also sought to follow the emergent process of integrating NIMH grant

review personnel and procedures with those of NIH. The Workgroup recognized,

however, that its own timetable would not permit giving serious consideration to how an

altered review process might affect mental health research in general, and prevention

research in particular.

Key Findings

Presented below are the Workgroup’s major findings regarding gaps in prevention

research within the three major domains of prevention research: risk-factor (or preintervention) research; preventive intervention research; and preventive services

research. An additional--and very important--potential gap should be noted: Prior to

the NIMH reorganization, NIMH had few mechanisms in place to encourage and

accelerate the transfer of research knowledge across prevention research domains. It

is not yet clear how the reorganization has affected this issue. Given this uncertainty,

administrative recommendations presented in Section V suggest ways to strengthen

the transfer process. 

Pre-Intervention Research 

NIMH has an extensive portfolio of research related to the origins of mental disorders. 

As coded by NIMH program staff, some 850 NIMH research grants active in FY 96 were

identified as being potentially relevant to risk-factor or pre-intervention research. The

Workgroup’s pre-intervention research subcommittee reviewed grant abstracts on risk

and protective factors for the major psychiatric disorders and other relevant targets of

prevention studies. Excluded from their review were abstracts on treatment or

preventive intervention (which were reviewed by the preventive intervention research 

subcommittee), as well as animal studies and basic neuroscience. 

To summarize the content and to identify gaps, Workgroup members analyzed the

grant abstracts by multiple descriptive categories that included: target outcome (mental

disorder or component, general functioning, psychological characteristics, social

adjustment, or medical disorder); sample source (universal, selective, indicated);

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demographic characteristics; study design (cross-sectional vs. longitudinal); and

classes of risk factors based on either individual characteristics (e.g., demographic

features, genetic risk status, developmental period, temperament and/or personality

attributes, gender) or exposure to a stressor or situation (e.g., social context, violent

crime, neighborhood and its resources, family, sociocultural factors).

Additional sources of this review included expert testimony to the Workgroup, review of

recent literature on methodology and risk and protective factors for psychopathology,

reports from advisory groups on prevention, and information on risk-factor research

from several other agencies and foundations outside of NIMH. 

Gaps in pre-intervention research

 o Sufficient data are lacking from population-based, prospective cohort, high-risk,

 and family studies to provide an empirical basis for choosing the timing and target 

 groups for prevention strategies, particularly those using a selective or indicated 

 approach.

 

o The risk-factor research portfolio is unevenly balanced with respect to both the

public health significance and the severity of particular target outcomes. 

o A relatively limited amount of risk-factor research is focused on populations with

particular combinations of gender, culture, and developmental stage (such as

adolescent girls in specific ethnic or cultural groups). 

o Little interdisciplinary collaboration exists among key domains of risk-factor

research. Also, mechanisms are lacking for translating findings in basic science,

genetics, and risk factor/pre-prevention research into applied prevention research. 

o Dramatic advances in have occurred in knowledge about the role of genetic and

biologic risk factors for mental disorders. However, little systematic research has

explored the interaction of these factors with psychological and environmental

factors or the potential translation of knowledge about genetic and other biological

risk factors into prevention intervention programs, or the diverse impacts--positive

and negative--of such programs.

 

Preventive Intervention Research

The Workgroup obtained from all NIMH divisions and branches 188 abstracts of grants

active in FY 1996 and nominated by NIMH staff as preventive interventions or as

relevant to prevention intervention research. Preventive intervention research

subcommittee members then coded these abstracts in categories to describe the type

of preventive intervention, the disorder or condition being prevented, the proximal

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outcomes of the intervention, the unit (e.g., individual, family) whose behavior is

targeted for change; the population’s developmental level, and the length of followup. 

Gaps in preventive intervention research

o Many preventive intervention studies currently in the NIMH portfolio are not

characterized as such, and are not included in planning for prevention. 

o Studies on relapse prevention and comorbidity prevention are not currently

included along with universal, selective, and indicated strategies in planning

prevention research. 

o Scientific initiatives to advance each level of preventive intervention and bridge

across levels have not been systematically identified.

o Preventive intervention in the portfolio has tended to focus on a limited number of

disorders, such as depression and conduct disorder, while relatively less attention

has been paid to development of interventions to prevent other mental disorders,

such as anxiety disorders and antisocial and borderline personality disorders.

o Preventive intervention strategies have primarily focused on changing individuallevel processes, giving less attention to change in other, larger units such as family,

school, and community, and how these larger units interact with individual-level

factors and with each other to lead to the development of mental disorders. 

o Research is lacking on methods of collaborating with communities to develop

prevention trials and to encourage their adoption of well-evaluated prevention

programs.

o Very few preventive trials focus on intervening during prenatal or early infancy

periods, when malleability may be high. 

o Few research interventions to prevent recurrence or comorbidity focus on children

or adolescents, despite considerable evidence of the recurrence of many mental

disorders and the development of comorbid disorders across childhood and

adolescence.

o There is a lack of systematic attention to the effects of preventive interventions

across cultures, genders, and life stages.

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Preventive Services Research 

Gaps in preventive services research

o Although NIMH has a relatively large and well-developed research program that

examines mental health treatment services in large-scale, real-world settings, that

program does not encompass research on preventive services. In fact, a review of

the NIMH research portfolio reveals that virtually no preventive services

research of any kind is being sponsored by NIMH in any of the three major

components of health services research: a) organization and financing; 

 b) clinical services research; and c) dissemination research. Additional gaps 

 related to preventive services research were identified :

o There are few scientists in the prevention field with training in health economics. 

This background is critical for adequate evaluation of the costs and benefits of

preventive intervention programs.

o While there is substantial effort to identify the cost-effectiveness of treatment and

other mental health services, there has been little translation of cost-benefit

analyses to preventive interventions.

o Basic data are scant on the cost and impact of mental disorders compared with

other chronic disorders. 

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 Recommendation 1 for an expanded definition of research is discussed on page 23. 5

29

IV. MAJOR RESEARCH INITIATIVES RECOMMENDED

 

Based upon the Workgroup’s assessment of the current NIMH prevention

research portfolio and the opportunities available to NIMH to advance prevention

research in the coming decades, the following research initiatives are

recommended for consideration by the National Advisory Mental Health Council

and the Director of NIMH: 5

> Recommendation 2: 

 Strengthen Epidemiologic Foundations of Prevention Research

o NIMH must invest in obtaining fundamental epidemiologic information about

the prevalence and incidence of mental disorders in the United States

population across the life span and the factors that contribute to their onset

and course. In addition, the Institute should begin planning for periodic

monitoring surveys of mental disorders in adults--including geriatric

populations--that can provide fundamental trend data on changes in patterns

of mental illness over time. These data are essential to strengthen the

empirical basis for selecting appropriate targets for prevention interventions

and for assessing the potential social and personal impact of prevention

efforts. Planning for obtaining the relevant data on children and youth should

be coordinated with planning for the new NIMH-sponsored national

epidemiological study of mental disorders in children and youth. NIMH should

support the development of optimal methods for assessing mental disorders

in the general population. 

Until quite recently, adequate data were unobtainable on the magnitude and risk

factors for mental disorders in children and adolescents in the community, and

prospective evidence for the predictive significance of risk factors for the major mental

disorders has been limited. However, advances in the classification and identification

of mental disorders, combined with improvements in community survey methodology,

now make it possible to obtain a more accurate picture of how mental disorders are

distributed in the U.S. population at all stages of development, and how those disorders

arise. 

Two major epidemiologic surveys on adults sponsored by NIMH--the Epidemiologic

Catchment Area (ECA) study and the National Comorbidity Survey (NCS)--have been

invaluable resources for the field, but the ECA was conducted almost two decades ago,

and the NCS conducted a decade ago. It is important now to build upon the baseline

knowledge derived from these studies to obtain trend data through surveillance studies

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that can aid in pinpointing both problems and progress in combating mental disorders

across the age spectrum.

In addition to the pioneering community surveys of mental disorders in adults already 

conducted, recent developmental work in the epidemiology of child and adolescent

disorders has paved the way for progress in this area as well. NIMH now needs to

capitalize on these advances to obtain national data on incidence and prevalence of

disorders in children and adolescents and the risk and protective factors germane to

these disorders. Prospective longitudinal cohort studies are necessary to aid in

identifying premorbid risk and protective factors that are powerful and potentially

malleable, as well as changes in the expression of mental disorder across the life span. 

These data are essential for planning and prioritizing prevention research and other

key components of the NIMH research portfolio. 

> Recommendation 3:

 Stimulate Pre-Intervention and Intervention Studies of Early Childhood Risks 

for Adverse Developmental Outcomes

o NIMH should encourage pre-intervention studies of prenatal, perinatal, and

early-life risk and protective factors that are relevant to a variety of negative

mental health outcomes in childhood, adolescence, and adulthood. 

Intervention trials focused on modifying these risk and protective factors

should be designed to enable long-term follow-up to test effects on the

development of mental disorders and adverse outcomes across

developmental periods. 

For example, NIMH should promote studies of children at high risk for mental disorders

as a result of biological or environmental aspects of parental mental illness and other

adverse prenatal and perinatal conditions. The high-risk approach should be

expanded across disorders to develop hypothesis-based research on risk and

protective factors for multiple outcomes, as well as those that convey increase risk of

specific outcomes. Integration of both biological and psychosocial factors is a critical

component of the next generation of risk studies. 

Adverse early experiences appear to place individuals at risk for a range of disorders

and subclinical conditions. Therefore, placing special emphasis on risk and protective

factors in early life that may affect a variety of mental health outcomes, such as

parenting style and nurturance and their relationship to parental psychopathology,

could be a particularly effective preventive strategy. 

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> Recommendation 4:

 Expand Research on Depression and Anxiety Across the Life Span

o NIMH should facilitate rapid progress in research on the prevention of

depression and anxiety disorders in children, adolescents and adults, using a

wide range of strategies. This focused effort is justified by the extensive

morbidity, disability, and mortality attributable to depressive disorders and by

the opportunity for research that can lead to community-based tests of these

interventions as well as to dissemination studies. NIMH should support all

levels of prevention research on depression and anxiety, particularly with

respect to their comorbidity with one another, and with medical illness across

the lifespan. 

 

Emerging research findings now provide a firm basis for intervention studies to prevent

depressive disorders and anxiety disorders. First, epidemiologic studies indicate that

major depressive disorder and anxiety disorders place a serious burden of suffering on

the American public, and developmental psychopathology studies have provided

considerable evidence about risk factors for the development of depression. Second,

prevention studies in both community populations and in clinical settings provide

encouraging evidence of the efficacy of specific, well-characterized interventions in

preventing the onset and relapse of depressive episodes. Emerging evidence also

suggests that there are several strategies to prevent and minimize disability related to

anxiety disorders. These research advances provide an important opportunity to

accelerate the development of multiple levels of effective preventive intervention

strategies as well as mechanisms for their delivery to the public.

Major depression currently ranks as the fourth leading cause of illness-related disability

affecting the world’s population, and by 2020 is projected to rank second. Depression

is often recurrent, a major source of suicide, and strongly associated with a number of

other disorders (e.g., drug abuse, social phobia and panic disorder, and physical

illness). Findings from large-scale community surveys indicate that as many as onequarter of the U.S. adult population may suffer in their lifetimes from depression,

anxiety, or their combination. Like the depressive disorders with which they often cooccur, anxiety disorders tend to be chronic, and are associated with significant 

psychological suffering and distress, physical illness, and even death.

Diverse biological and psychosocial risk factors for major depression have been

identified, including a genetic predisposition, major negative life events (e.g.,

unemployment, divorce or separation), medical illness, ruminative coping style, and

gender. Although the mechanisms by which these risk factors lead to depression are

not well understood, identification of these risk factors provides an opportunity to

develop selective and indicated preventive interventions. Shifting from universal to

selective and indicated preventive strategies based on high symptom levels of

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depression and/or a history of parental depression has led to a dramatic improvement

in the outcome of prevention studies of depression. Likewise, a recent controlled 

preventive intervention study of newly unemployed workers revealed a decrease in 

depressive episodes over a 2-year period following the intervention. Similarly, in

clinical settings, long-term preventive maintenance treatment programs have been

shown to prevent recurrence for up to 5 years among patients with major depression

who previously had been experiencing episodes every 18 months to 2 years. More

recently, similar prevention studies have been successfully applied to anxiety disorders

in youth. Future studies that integrate both depression and anxiety in preventive

intervention efforts are strongly recommended.

> Recommendation 5:

 Refine and Advance the Empirical Basis for Conduct Disorder Prevention

 Research

o NIMH should integrate a growing body of basic research on the biological,

psychosocial, and environmental roots of conduct disorder and its correlates

and foster the inclusion of multiple risk indicators in prevention trials of

conduct disorder and associated behavioral problems in children,

adolescents, and young adults. To identify children at highest risk for

conduct disorder and its consequences, methodologic studies should be

encouraged to assess conduct symptoms and correlates. Intervention studies

should be based on empirical findings on how biological, psychological, and

community influences affect the development of conduct disorder and on

developmental periods likely to be especially responsive to intervention. Of

particular importance is research to strengthen the knowledge base on

conduct and other behavior problems that emerge during adolescence. NIMH

should actively seek collaborations with other relevant organizations and

agencies to support such studies. 

Conduct disorder, attention deficit/hyperactivity disorder, and developmental learning

disorders are leading causes of educational failure, secondary mental disorders

including substance abuse and depression, accidents, injuries, unemployment, physical

illness, and criminal activity. They therefore have widespread implications beyond the

mental health system. Youth with behavior problems have been targets of study in the

education system, the criminal justice system, social services, and health care facilities

(both general medical services as well as those for mental and substance abuse

disorders). Several promising prevention programs have generated data regarding

effective targets and program features for preventing the development of conduct

disorder and its consequences. However, the cost-benefit ratio of such programs must

be evaluated systematically to determine resource allocations across all domains of

mental disorders.

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Research is necessary to provide basic information regarding the classification,

measurement, and pathways to the development of conduct disorder, as well as the

links between conduct disturbances and other domains of psychopathology, including

attention deficit/hyperactivity disorder, substance use disorders, and affective

disorders. Although there is abundant information on the pathways and risk factors for

the development of conduct problems, interventions that address the multidisciplinary

integration of risk factors have only recently been implemented in treatment and

prevention programs. Further studies are needed to examine how developmentally

specific individual, social, and biologic risk factors interact with their broader familial,

community, and cultural contexts.

Several major considerations should be highlighted in the design and support of future

studies: 1) Before embarking on new, large-scale studies in this area, NIMH should

carefully evaluate and integrate results from ongoing preventive trials of conduct

disorder in which it is investing considerable resources to modify multiple risk factors

for early-onset conduct disorder; 2) NIMH should encourage development of studies of

adolescent-onset conduct disorder, which may require different prevention strategies

than studies of childhood-onset conduct disorder, since these disorders are associated

with different correlates and risk factors; and 3) Future prevention studies should

incorporate in their design and evaluation comorbidity between conduct disorder and

other psychiatric disorders, including attention deficit/hyperactivity disorder,

depression, and substance abuse disorders. 

> Recommendation 6:

 Broaden Disorders and Populations Targeted for Prevention Research

 

o NIMH should broaden the disorders and populations targeted for

intervention in four ways: 1) expand the scope of disorders targeted for

intervention; 2) stimulate studies for reducing relapse; 3) increase preventive

interventions with larger social units, such as families, peers, schools, and

communities; and 4) stimulate studies of risk and protective factors and

processes and interventions in specific ethnic groups.

o NIMH should expand the scope of its prevention research program to

encompass disorders and types of populations now underrepresented in the

portfolio, with an emphasis on severe and persistent disorders (e.g., 

schizophrenia, bipolar disorder, anxiety disorders, and personality disorders). 

Certain disorders are underrepresented in the NIMH prevention research portfolio,

such as schizophrenia, severe personality disorder, and other chronic and disabling

disorders. Schizophrenia is a particularly important frontier for prevention research,

given its extremely high human and financial cost to those who are ill, their families,

and society at large. More studies are needed that build on a growing international

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body of research knowledge to lay the groundwork for indicated prevention

interventions for schizophrenia, as well as the prevention of comorbidity, disability, and

relapse. More specifically, NIMH should: a) extend community-based studies beyond

depressive disorders and conduct disorder to include anxiety disorders, schizophrenia,

and substance abuse; b) extend clinically based studies beyond depressive and anxiety

disorders to include bipolar disorder, schizophrenia, and severe personality disorders;

c) extend relapse- and disability-prevention studies beyond depression and

schizophrenia to include bipolar disorder and anxiety disorders.

 

While not focused necessarily on any particular mental disorder, one important and

challenging part of the NIMH prevention research domain is the prevention of suicide. 

It is a very difficult area for research because completed suicide occurs infrequently,

even in populations with mental illnesses, and the relationship between preventing

suicidal thoughts and preventing suicidal behavior is not yet clear. NIMH should use a

variety of means--including convening methodologic experts--to encourage the

development of new methodologies for studying suicide and suicide prevention. It

should also foster a developmental approach to suicide prevention research that

examines similarities and differences in risk and protective factors for severely selfdestructive behavior in pre-adolescence, adolescence, adulthood, and old age. NIMH

should collaborate with the Centers for Disease Control, whose preventive mandate

includes the prevention of suicide. 

o NIMH should stimulate studies of biological and psychosocial intervention

approaches--singly and combined-- for reducing relapse and disability in

many major mental disorders. Research on relapse prevention should include

bipolar disorder and anxiety disorders in addition to those disorders currently

under study--primarily schizophrenia and depression.

In disorders known to have high relapse potential, acute treatment studies (often

involving 6 weeks of treatment or less) are insufficient. Indeed, well-planned relapse

prevention should be considered a part of clinical trials. 

o The targets for preventive strategies should be broadened to increase

interventions with larger social units, such as families, peers, and schools and

communities, where research evidence supports their effects on increasing or

decreasing the likelihood of mental disorders. Increased research should

examine how these social environments interact with individual-level factors

and with each other to affect the development, onset, course, and recurrence

of mental disorders, and how to collaborate with communities to develop

efficacy, effectiveness, and dissemination trials.

o NIMH should stimulate studies of risk and protective factors and processes

that affect the development of mental disorders in specific cultural and ethnic 

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groups, and encourage the development of preventive interventions that are

culturally appropriate and effective.

> Recommendation 7:

 Expand Studies on Comorbidity Prevention

o NIMH should sponsor a research effort to identify systematically risk and

protective factors for co-occurring illnesses, with particular attention to the

links between mental and substance-abuse disorders, and between mental

and medical disorders. These studies should focus on identifying the risk

factors and developmental processes--including biological, psychological,

family, and community influences--that lead some individuals to have more

than one disorder. 

o Based on such pre-intervention studies, the Institute should encourage

translation of strong empirical findings into the design and testing of both

community-based and clinically based interventions to prevent the

development of comorbid disorders.

The robust epidemiologic evidence of the high magnitude of comorbidity among mental

disorders (fully half of all psychiatric patients have more than one mental disorder) and

between mental disorders and other disorders has important implications for prevention

research. Individuals with co-occurring disorders tend to have more serious disability,

greater severity, worse outcome and poorer treatment response than those with a

single disorder. In addition, some relatively predictable trajectories have been

identified for the accretion of comorbidities. For example, early anxiety, attention deficit

disorder and conduct disorder are all related to the subsequent onset of depression;

and nearly all of the mental disorders are associated with substance use disorders. 

Potential interventions to prevent comorbid disorders--such as modifying common risk

factors that lead to multiple comorbid disorders, or treating symptoms or consequences

of primary disorders that lead to the onset of secondary disorders--have received

relatively little attention but may have considerable promise.

 

Designing effective prevention programs for co-occurring disorders will require

substantial pre-prevention research to investigate how certain comorbid associations

occur. Common etiologic processes may lead to diverse sets of comorbid disorders or

diverse etiologic processes may lead to specific sets of comorbid disorders. Prevention

and intervention strategies to prevent co-occurring disorders need to build on preintervention research that clearly differentiates primary and secondary disorders and

identifies the causal mechanisms that lead from one disorder to the next. NIMH should

follow the 1993 recommendations of Kessler and Price regarding strategies for

studying the mechanisms for comorbidity and assessing the implications of comorbidity

for prevention. Family and twin studies, as well as prospective longitudinal cohort

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studies are particularly important paradigms that should be encouraged to address

mechanisms for how and why some mental disorders cluster together in individuals. 

To identify linkages between mental and physical disorders, NIMH should stimulate

interdisciplinary studies that include pilot intervention studies designed to clarify these

interactions and suggest potential targets for more extensive trials. Such trials should

examine both the prevention of adverse physical health consequences in people with

mental illness and the prevention of mental disorders in those with physical illness and

disability. NIMH should work with staff of other NIH institutes, the NIH Office of

Disease Prevention and the NIH Office of Behavioral and Social Sciences Research to

co-fund initiatives in this area and to encourage cross-fertilization across prevention

research areas related to mental disorders, other chronic illnesses, and infectious

diseases.

> Recommendation 8 :

 Develop a Program of Preventive Services Research,

 Including Prevention Policy Research

o Given the paucity of preventive services research in the NIMH portfolio,

NIMH should provide both the staffing and financial resources needed to

stimulate and nurture the new research area of preventive services research,

with the following areas of emphasis:

- NIMH should support trials of well-assessed preventive interventions in

various real-world settings under diverse organizational and financing

frameworks. Because of the potentially high cost of this research, the

Institute should carefully select the most promising interventions, and

should vigorously seek collaborative funding with other agencies and/or

private foundations.

 

- NIMH should foster dissemination research to discover how preventive

interventions already shown to be effective can be disseminated to new

settings, and how they can be implemented and maintained. 

- NIMH should encourage studies that explore high-priority preventive

services research issues, such as: 1) the delivery, cost, and financing of

preventive services; 2) the assessment and comparison of existing

community-based preventive services to identify candidates for more

systematic study ; and 3) the development of improved methods for

specifying and measuring the expected outcomes of short- and long-term

preventive interventions, especially functional outcomes of preventive

services, such as individual productivity, cost-efficacy, and cost-offset. 

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- NIMH should stimulate research on how changes in social and economic

systems, policies, and laws, as well as social and cultural norms may

affect the prevention of mental disorders.

 

An interest in translational research--a high-priority issue for NIH and NIMH--means

discovering through systematic studies how research findings are and could be used in

real-world settings. In fact, the development of research-based preventive

interventions is not complete until they have been used and assessed in such settings

and service systems. It is precisely at this final research stage, however, that the

translation process often founders. Some promising prevention research findings

never leave the pages of research journals, while others are adopted outside the

research community with no systematic tracking of where and how often they are

implemented--and in what form, to what effect, and at what cost. Furthermore, a small

number of scientifically validated prevention interventions compete in the real world

with a vast array of prevention approaches of untested and unproven merit. 

Given the need for research to inform decisions about the provision, cost, financing,

and improvement of mental health preventive services in a variety of clinical and

community settings--including decisions about the allocation of health care resources

through managed care--the current lack of NIMH preventive services research is of

particular concern. Overcoming this large research gap will require a multifaceted

NIMH program of assessment and capacity-building to give impetus to this important

area of research. Broadened support is needed to stimulate researchers to conduct

preventive services studies and to foster continuity in the cycle of preventive services

research implementation. Recruitment to the prevention field of scientists with training

in health economics is a particularly important priority.

In a developing research area such as preventive services research, attempts to

strengthen the science by stressing hypothesis-testing and model-driven studies may

undervalue the importance of descriptive studies that incorporate measures of real

outcomes. However, rigorous, descriptive studies--particularly those that capitalize on

the natural variation of similar types of service delivery across settings--provide an

invaluable resource for later hypothesis generation, and should be encouraged,

NIMH needs to foster studies of the natural history and outcome of: a) interventions

generated within the service community that have not yet had systematic assessment;

and b) the translation of systematically developed prevention research interventions

from the laboratory setting into the community. Studies of the latter type should include

both the cost effectiveness and the efficacy of that translation. 

A problem in the translation of all intervention results to services research, not just in

the prevention area, is the lack of crosscutting expertise. Intervention researchers

rarely know how to examine their results in services settings; services researchers

rarely seek to test interventions proven to work in academic or other research settings. 

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NIMH therefore needs to expand the pool of researchers qualified to conduct

preventive services research and encourage cross-training and collaboration between

health services researchers and prevention researchers focused on mental disorders.

Collaboration is likely to be particularly fruitful in settings with natural access to the

populations receiving preventive services, such as primary care offices, schools,

courts, homes, and day-care centers. Working in such settings can enhance the

integration of effective mental health interventions into service settings outside the

specialized mental health service delivery system. 

> Recommendation 9:

 Encourage and Support Long-Term Followup in Prevention Research

o NIMH/NIH should facilitate essential longitudinal followup in prevention

research through appropriate grant review and funding mechanisms. 

Long-term studies are essential for understanding the etiology of mental disorders and

the enduring impact of preventive interventions. At present, two-thirds of NIMH-funded

community-based preventive interventions report followup assessments ranging from 1

year to more than 6 years, yet we now know that the most desired effects may be

observed as long as 15 years after an intervention. Among prevention intervention

studies of clinical populations, approximately one-half report 1-year to 3-year followup

assessment of patients. 

Many approaches need to be used to maintain study populations and encourage longterm followup. Initial review groups (IRGs) should be educated about the critical

importance of longitudinal followup studies for prevention research. When reviewing

ongoing longitudinal studies and confronted by grant proposals with mild flaws or areas

requiring clarification, reviewers should be encouraged to safeguard research

continuity by using the full array of available responses, which include deferral and

having direct discussions with applicant investigators as part of the review process to

clarify issues and avoid unnecessary funding lapses when sample maintenance is

critical. Other approaches include program staff’s offering bridging grants to maintain

samples where reviews indicate a high likelihood of funding of longitudinal followup

studies; offering small tracking grants to facilitate contact with longitudinal samples

between assessment points; and allowing investigators to propose studies of longer

than 5 years duration when justified by scientific objectives and methods. However,

proposals should be reviewed for suitability for long-term funding, and must receive

periodic reviews of program achievements.

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> Recommendation 10:

 Build Prevention Research Capacity, Especially through Training Grants

o NIMH/NIH training grants should provide support for the training

infrastructure, such as salaries for training directors and increased trainingrelated expenses

o NIMH/NIH stipends for research trainees should be raised above current

levels--to at least $30,000 a year for postgraduate trainees--with no decrease

in numbers of training slots. Low stipends are a deterrent to individuals from

poor economic backgrounds and/or with loan debts, and exacerbate the

shortage of minority prevention researchers. 

o NIMH should explore development of an initiative to recruit qualified

minority researchers into the field of mental disorders prevention research. 

o NIMH-funded training and fellowship directors should be encouraged to

combine trainees from more than one discipline (e.g., epidemiology and

behavioral science, or statistics and biological science), and prevention

research training programs should expose trainees to the concepts and

methods of a wide variety of disciplines relevant to prevention research. 

o NIMH should seek or develop training mechanisms to encourage

investigators in other research fields (e.g., physical disease prevention

research, health services research, treatment research) to collaborate with or

conduct prevention research related to mental disorders.

There is a pressing need to train increased numbers of prevention researchers to

continue the methodological and substantive advances essential for this field. In

addition, in mental disorders prevention research, as in many other important mental

health research areas, minority researchers are under represented. A number of

current limitations on training grants provide disincentives that hamper recruitment and

the systematic development of the field. NIMH needs to address these issues

immediately. From a more long-term perspective, NIMH should periodically assess the

impact of its training programs on the growth, stability, and quality of fields such as

prevention research and epidemiology research. 

Sustaining the health and growth of prevention research as a field requires an ongoing

supply of researchers of many types and disciplines. Because training in this area

should foster a close interchange between research on prevention of physical illness

and on prevention of mental illness (as occurs in the NIH HIV research program), NIMH

should stimulate collaboration in training-related initiatives across NIH institutes and

other components of the Public Health Service. For example, NIMH should work with

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NIH to encourage minority students as early as high school to consider careers in

prevention research.

o While investigator-initiated research projects (RO1s) are and should

continue to be the mainstay of the NIMH prevention research program, NIMH

should fund and stimulate use of a variety of appropriate support mechanisms

for prevention research and training.

Awareness of the relevance of basic science for prevention could be expanded by

issuing requests for applications that solicit basic research studies with clearly stated

implications for prevention, and through support of collaborative studies between basic,

clinical, and prevention research. NIMH could and should also do more to stimulate

cooperative research grants when multisite studies are needed. It should encourage

systematic consideration of multidisciplinary collaborations in the review of prevention

research. In addition, the Institute should encourage creative use of supplements to

existing research grants to stimulate and expand prevention research training

opportunities. The Workgroup endorses continued NIMH support of prevention

research centers, which can be a stimulating and trend-setting force for the field. But

the Institute should strongly encourage centers to foster interdisciplinary research and

training of the highest standard. Toward this end, center staff should be required to

compete for RO1 grants and training grants that amplify their areas of concern. 

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V. RECOMMENDATIONS FOR 

NIMH LEADERSHIP AND CONTINUITY

 IN PREVENTION RESEARCH ACTIVITIES

 Context: Reorganization of NIMH and Grant Review Process

The Workgroup supports many of the principles that have guided the recent structural

reorganization of NIMH. Those principles include an overarching concern with

enhancing opportunities for transfer from basic research to clinical practice and

services delivery, as well as the recognition that research on the prevention of mental

disorders needs to be more closely linked to basic behavioral science research and to

AIDS prevention research. The new structure of prevention research programs at

NIMH provides an exciting opportunity to view prevention research through a new lens,

and to consider new types of collaboration, cooperation, and cross-fertilization with

related and vital areas. However, the Workgroup is concerned about the potential for

dividing and diffusing responsibility for identifying new scientific opportunities and

encouraging the systematic transformation of promising leads into practical prevention

interventions. Thus, the recommendations to follow address critical leadership issues

raised by the new structure of prevention research

Given the fact that the reorganization of NIMH grant review is still in an early stage, it

would be premature for the Workgroup to provide specific guidance. However, it is

clear that any decision regarding the locus and structure of review of prevention

research--whether within NIMH alone or within an NIH-wide review committee--must

allow for adequate multidisciplinary representation on review committees and must

encourage the conduct of multidisciplinary research.

 Recommended Initiatives

> Recommendation 11:

 Provide Scientific Leadership for Prevention Research

o NIMH should support continuation of the NIMH staff’s Prevention Research

Consortium and recommends the following revised mission: The Consortium

should serve as a forum for prevention research, collaboration, integration,

and cooperation across NIMH research programs. Its functions should

include stimulating linkages among risk-factor, preventive intervention, and

preventive services research and fostering the rapid translation of risk-factor

research into the development of prevention trials. 

o NIMH should convene a standing Prevention Research Advisory Group

(PRAG), chaired by a scientist with interdisciplinary background and

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experience in prevention research, to promote and direct prevention research

and training within NIMH and to provide guidance to the NAMHC and the

Director of NIMH. That group should represent expertise in epidemiology,

developmental psychopathology, preventive intervention development,

prevention science, methodology, and the conduct of community-based

prevention trials. 

Responsibilities of the PRAG should include: recommending priorities for

targets of prevention research; encouraging interdisciplinary research;

heightening investigators’ awareness of the importance to prevention of basic

work on risk processes; and facilitating communication and integration of

research between NIMH and other relevant agencies. This group would also

assist the NAMHC in overseeing the integration of pre-intervention and

prevention intervention research to maximize knowledge gained in relevant

areas such as genetics and developmental neuroscience and to alert those

engaged in prevention research to relevant scientific advances. Members of

the NAMHC should be ex officio members of the PRAG, with NIMH division

directors serving as ex officio research information resources.

The impact of the recent reorganization of NIMH on prevention research and its

leadership is still unknown. Prevention research at NIMH was never totally centralized

under the former Prevention and Behavioral Medicine Research Branch and its

predecessors. However, the Branch served as a single, identifiable focal point for preintervention and intervention research within a single division. 

At present, there is no single focal point for prevention; the pre-intervention and

intervention programs are in separate divisions. While the current organization has

potential benefits--including improved linkages with clinical and basic research

programs that are relevant to prevention research--the special mechanisms

recommended in this Section are intended to assure that essential linkages and

leadership in fact occur. 

o To start the process of assessing a group of scientific issues critical to the

development of prevention research at NIMH, the PRAG should collaborate

with the NIMH Prevention Research Consortium to plan and execute in the

next year a series of Prevention Research Summits, which resemble

consensus conferences. They should summarize the state of knowledge

about risk and protective factors and processes, preventive interventions, and

prevention research for each major mental disorder and identify common risk

and protective factors across disorders. To encourage a unified view within

the field of its major accomplishments, scientific opportunities, and needed

research, a summit should recommend to the NAMHC the highest research

priorities across disorders and phases of research, based on public health

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need and scientific opportunity.

 

Foci of these summits should include: a) identifying potentially malleable populationlevel risk and protective factors that have been scientifically demonstrated to alter the

probability of developing mental disorders and that should be targeted in universal and

selective prevention trials; and b) developing a consensus on major risk factors for

mental disorders that should be targeted by selective and indicated interventions. The

broad range of risk factors considered should include severely stressful life

experiences (such as childhood experiences of sexual and physical abuse), medical

illness, and parental mental disorder. A summit should also identify processes that

lead from risks to disorder, and should include a focus on biological, psychological, and

social processes and the relations among them. 

Methodologic issues relevant to adequate evaluation of prevention programs should

also be addressed by the summits. Measurement of risk factors and target disorders is

a critical aspect of preventive intervention research. Reliable measures of these

domains with good predictive validity are critical to identify targets and measure the

outcome of prevention programs. Ongoing efforts to enhance measurement of

psychiatric disorders and relevant risk factors in adult and child epidemiology must be

represented adequately in the prevention field. Likewise, statistical approaches that

capture processes rather than pre-and-post measures will provide a more realistic

representation of both the pathways to mental disorders and the changes produced by

prevention programs. 

Prevention researchers, treatment researchers, and services researchers supported by

NIMH are all concerned with the development of efficacy and effectiveness trials in

their respective arenas. Currently, however, these researchers do not communicate

regularly, nor is there a clear sense of how their respective research programs are

related and could benefit one another. For example, prevention researchers have

pioneered strategies for moving from population-based research to randomized

intervention trials; that knowledge could be of critical importance to treatment

researchers and services researchers. Conversely, innovations developed by services

researchers who have focused on issues of services access and cost effectiveness

could be of immense value to prevention researchers and intervention researchers. 

NIMH should expand the envelope of knowledge around research methodology by

fostering these linkages and exchanges.

NIMH should also hold a series of conferences bringing together intervention

researchers from AIDS research centers, clinical research centers, prevention research

centers, and other intervention sites that draw on and integrate a wide range of

intervention technologies, including biological, behavioral, organizational, and

community-based approaches. One product could be a set of initiatives for research

on common behavior-change issues, such as encouraging motivation for change,

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maintaining change, and preventing recurrence of problems. In addition, NIMH should

convene prevention, treatment, and services researchers in a series of workshops to

explore strategies for resolving methodological problems and developing creative new

methods for efficacy and effectiveness research.

> Recommendation 12:

 Provide Leadership in Prevention Grant Review

o Because of the essential interdisciplinary nature of prevention research,

review panels for NIMH prevention research must be interdisciplinary in

composition, including more than one expert in each relevant biological,

psychological, and social science research area. Review panels should

include experts in epidemiology, developmental psychopathology,

methodology, and conduct of community-based prevention trials.

o NIMH/NIH should develop review criteria to maximize the potential for fair

review of applications that attempt to bridge disciplinary approaches to

prevention research.

The interdisciplinary nature of prevention research is a scientific necessity and an

asset for the mental health field. But it presents administrative and review challenges

for researchers that NIMH must address and overcome. Of particular concern at

present is the review process for NIMH prevention research, which itself is currently

undergoing review and likely modification. The plan to have NIMH research proposals

reviewed along with proposals from other NIH institutes provides an opportunity to

enrich prevention science. Reviewers from other disciplines and areas will bring new

perspectives, methodologies, and models to the critical evaluation of NIMH prevention

research. At the same time, NIMH-funded research has pioneered advances in

prevention science that may not be familiar or well understood by scientists from other

institutes. Some examples include the dynamic and iterative relationships between

epidemiological research and the design of prevention trials, the critical role of

observational methodology, and the increasing importance of new statistical techniques

for modeling developmental trajectories. 

Unless reviewers are well grounded in these and other areas, some of the most

powerful and promising NIMH research may not be properly reviewed by NIH-wide

committees. NIMH should develop guidelines to facilitate the selection of reviewers

who bring rich and specified competencies and experience to centralized review

groups. Additionally, procedures should be developed to orient new reviewers and to

provide training as needed on a continuing basis. 

In making grant review decisions that affect existing NIMH funding investments in

prevention research, reviewers should be encouraged to recognize the rich variety of

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ways to develop and test valuable approaches to prevention. The search for scientific

rigor--however desirable--should be tempered by public health pragmatism. For

example, AIDS prevention research has demonstrated the power of carefully chosen

atheoretical studies; such an approach should be given consideration in reviewing 

mental disorders prevention research. 

> Recommendation 13:

 Provide Leadership for Cross-Institute and Cross-Agency Linkages

o NIMH should take a leadership role in linking with other components of NIH

as well as research and service agencies relevant to the prevention of mental

disorders to foster collaborative community trials and to open up avenues for

research dissemination.

Collaboration across agencies is vital to share scientific advances, to eliminate

redundant efforts, and to make efficient use of resources. Collaborative efforts need to

be increased to study common risk and protective factors and processes, and to

develop and disseminate efficacious preventive interventions of interest to multiple

institutes and agencies. Many federal agencies are supporting and studying

interventions that could yield systematic information on mental health outcomes at

minimal additional costs. For example, failure to learn in schools and low attachment to

school, which are of interest to NIMH as important risk factors for mental health

problems, are of interest to the National Institute on Drug Abuse (NIDA) as risk factors

for drug abuse and to the Department of Education as risk factors for school failure. 

NIMH needs to increase collaborative efforts with these and other components of the

Federal Government to study common risk and protective factors relevant to mental

health outcomes and to develop and disseminate effective preventive interventions of

potential interest to many federal and nongovernmental organizations. 

> Recommendation 14:

 Provide Leadership in Prevention Research Dissemination

o NIMH should build upon the work of its NAMHC Communications Subgroup

to develop a plan for disseminating research findings to key target audiences. 

A central part of this plan should be the dissemination of prevention research findings--

particularly those relating to the cost effectiveness of specific interventions--to

researchers, public and private policymakers, service providers, and relevant

administrative personnel in health, mental health, educational, and community settings. 

Whenever possible, these dissemination efforts should be guided by findings from the

new NIMH dissemination research program to be developed within the proposed new

preventive services research program.

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Of particular importance, NIMH should take a leadership role in establishing a sciencebased prevention trial registry that includes mental and behavioral disorders. Just as

medicine now relies on registries to promote empirically sound approaches, the

prevention field also requires a registry system to identify and classify its trials and

scientific findings in an accepted, broad, and inclusive registry system. Such an

evidence-based prevention trial registry would enhance the transfer of knowledge to

practice and would lead to increased rigor in the prevention field. Prevention trials that

are part of a comprehensive prevention trial registry would service as a source for

selecting the best designs, measures, and intervention strategies within the domains of

both prevention and treatment.

For Further Reading

Gordon, Robert (1987): An Operational Classification of Disease Prevention. In: 

Preventing Mental Disorders: A Research Perspective, Jane Steinberg & Morton.

Silverman (Eds). Rockville, MD: Alcohol, Drug Abuse, and Mental Health

Administration (DHHS Publication No. (ADM) 87-1492), 20-26.

 Institute of Medicine, Committee on Prevention of Mental Disorders, Division of .

Biobehavioral Sciences and Mental Disorders (1994). Summary, Appendix A in

Patricia J. Mrazek and Robert J. Haggerty (Eds.). Reducing Risks for Mental

Disorders. Washington, DC: National Academy Press, 493-495.

NIMH Ad Hoc Committee on Prevention Research (April 1996): A Plan for Prevention 

Research for the National Institute of Mental Health: A Report to the National

Advisory Mental Health Council. Bethesda: National Institutes of Health (NIH

Publication No. 96-4093).

Prevention Research Steering Committee (March 9, 1993): The Prevention of Mental 

Disorders: A National Research Agenda (unpublished).

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APPENDIX A: 

Charge: NAMHC Workgroup on 

Mental Disorders Prevention Research

The National Advisory Mental Health Council (NAMHC) Workgroup on Mental

Disorders Prevention Research was created at the request of Dr. Steven Hyman,

Director of the National Institute of Mental Health (NIMH), to review the Institute’s

current prevention research portfolio and, of particular importance, to identify gaps and

opportunities for future research. At least two major issues have given rise to this

process: recognition of the value of the prevention research perspective (including its

developmental approach and its focus on nonclinical as well as clinical settings); and a

growing realization that severe mental disorders, which are now underrepresented in

the NIMH prevention research portfolio, are not likely to be amenable to primary

prevention interventions with our current knowledge base. Given these and other

issues bearing on NIMH prevention research, key areas for the Workgroup’s

consideration include:

1. Broadening the disciplinary base of prevention research--such as involving

treatment researchers (including pharmacologists) and services researchers--and

forging mutually enriching links with both the treatment research and services research

communities;

2. Developing better connections between prevention research, basic behavioral

science, and research on genetic and other risk factors for mental disorders;

3. Expanding the domain of NIMH prevention research beyond “primary prevention”

to include: a) the early identification of symptoms in a variety of mental disorders as a

basis for early intervention and the prevention of possible comorbidity (e.g., alcoholism

as a complication of social phobia) or complication (e.g., agoraphobia as a result of 

panic disorder); and b) the use of interdisciplinary (including both pharmacologic and

behavioral) approaches in relapse prevention in mental disorders with recurrent or

worsening courses;

4. Sharing with other areas of prevention research the knowledge gained in the

prevention of behaviors that confer risk of HIV infection. This knowledge base 

includes: approaches to identifying populations at risk; appropriate methodologies to

motivate behavior change; considerations of community in initiating and maintaining

behavioral change; and approaches for maintaining behavioral change over long time

periods. 

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48

5. Extending beyond childhood the developmental perspective, which has been an

important tool in some areas of prevention research, and exploring its potential benefits

in research aimed at preventing HIV infection. (However, the prevention research

portfolio of the NIMH AIDS research program is not a focus of the Workgroup’s review.)

6. Including variables related to alcohol and drug abuse in prevention research on

mental disorders. 

Meeting under the leadership of Dr. Thomas Coates, an incoming Council member, the

10*-person Workgroup should submit its conclusions and recommendations to the

NAMHC in a brief (less than 30 pages) report for consideration at the Council’s

September 1997 Policy Session.** Because a substantial funding increase for the

Institute is unlikely given the current budgetary environment, the Workgroup’s

recommendations should not assume the availability of new funding.

---------

*Initially 12 members (1/97)

**Extended to February 1998 

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49

APPENDIX B:

Roster: National Advisory Mental Health Council

(All terms end 9/30)

CHAIRPERSON EXECUTIVE SECRETARY

Steven E. Hyman, M.D. Jane A. Steinberg, Ph.D.

Director Associate Director

National Institute of Mental Health National Institute of Mental Health

Rockville, Maryland Rockville, Maryland 

MEMBERS

Thomas J. Coates, Ph.D. (00) Michael F. Hogan, Ph.D. (98)

Professor Director

Director, AIDS Research Institute and Ohio Department of Mental Health

 Center for AIDS Prevention Studies Columbus, Ohio 

University of California, San Francisco

San Francisco, California Dale L. Johnson, Ph.D. (99)

Kathy Cronkite (00) Department of Psychology 

Mental Health Advocate University of Houston

Austin, Texas Houston, Texas 

Mary Jane England, M.D. (01) Robert L. Johnson, M.D. (99)

President Director of Adolescent Medicine

Washington Business Group on Health Department of Pediatrics

Washington, DC University of Medicine and Dentistry 

Ellen Frank, Ph.D. (01) Newark, New Jersey 

Professor of Psychiatry and Psychology

Department of Psychiatry Constance E. Lieber (98)

School of Medicine President

University of Pittsburgh National Alliance for Research on

Pittsburgh, PA Schizophrenia and Depression 

Apostolos Georgopoulos, M.D., Ph.D. (00)

Professor, Department of Physiology, Neurology Anne C. Petersen, Ph.D. (01)

 and Psychiatry Senior Vice President for Programs

University of Minnesota Medical School W. K. Kellogg Foundation

Director, Brain Sciences Center Battle Creek, Michigan

Veterans Affairs Medical Center

Minneapolis, Minnesota 

Ann M. Graybiel, Ph.D. (99)

Walter A. Rosenblith Professor

Department of Brain and Cognitive Sciences

Massachusetts Institute of Technology

Cambridge, Massachusetts 

Professor

 of New Jersey

Great Neck, New York 

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John Rush, M.D. (00) Professor of Psychiatry and Epidemiology

Betty Jo Hay Professor and Chair in Mental Columbia University College of Physicians

 Health and Surgeons and

Department of Psychiatry Chief, Department of Clinical and Genetic 

University of Texas Epidemiology 

Southwestern Medical Center New York State Psychiatric Institute

Dallas, Texas New York, New York 

Richard H. Scheller, Ph.D. (99)

Investigator, Howard Hughes Medical Institute

Professor, Department of Molecular and 

 Cellular Physiology

Stanford University School of Medicine

Stanford, California 

G. Richard Smith, Jr., M.D. (98)

Professor 

Director of Centers for Mental Healthcare 

 Research

Department of Psychiatry

University of Arkansas for Medical Sciences

Little Rock, Arkansas 

José Szapocznik, Ph.D. (98)

Professor and Director

Center for Family Studies

Department of Psychiatry and Behavioral 

 Sciences

University of Miami School of Medicine

Miami, Florida 

Joseph S. Takahashi, Ph.D. (99)

Investigator, Howard Hughes Medical Institute

Walter and Mary E. Glass Professor

Department of Neurobiology and Physiology

Northwestern University

Evanston, Illinois 

Senior Vice President for Programs

W. K. Kellogg Foundation

Battle Creek, Michigan

James G. Townsel, Ph.D. (01)

Professor 

Department of Anatomy and Physiology

School of Medicine

Meharry Medical College

Nashville, Tennessee 

Myrna M. Weissman, Ph.D. (00)

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

Harold E. Varmus, M.D.

Director

National Institutes of Health

Bethesda, Maryland 

Department of Defense

Robert A. Mays, Jr., Ph.D.

Colonel, U.S. Army

Deputy Chief of Staff

North Atlantic Regional Medical Command

 and

Walter Reed Army Medical Center

Washington, DC 

Department of Veterans Affairs

Thomas B. Horvath, M.D., F.R.A.C.P.

Chief Consultant for Mental Health

Department of Veterans Affairs

Veterans Health Administration

Washington, DC 

LIAISON REPRESENTATIVE

Center for Mental Health Services

Thomas H. Bornemann, Ed.D.

Deputy Director, CMHS

Substance Abuse and Mental Health Service

Administration

Rockville, Maryland

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