Health-Risking Social Behaviors: Moving Forward

The National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) have a long history of supporting investigator-initiated research and research training to enhance the scientific understanding of and effective interventions for a range of problems associated with youth violence. New technologies are emerging and basic research has promise for increasing our understanding of how biological factors operate in conjunction with other factors to contribute to violent behavior, psychopathology, and drug abuse. This article describes emerging areas and directions for research in this important area of public health.The views expressed are those of the authors and do not necessarily represent those of the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institutes of Health, the Department of Health and Human Services, or the U.S. Government.     

NIMH support of rural mental health

The National Institute of Mental Health (NIMH) emphasizes improved mental health and mental health services in rural areas through funding for research projects and research centers. NIMH also supports related activities including state planning, improvement of state data systems, protection of and advocacy for mentally ill individuals, disaster relief, professional training, and education concerning depression. Other important components include surveys, analyses, and public information, including support for a public hearing on rural mental health.     

Psychology research and NIMH. Opportunities and challenges

As an essential contributor to the scientific understanding of mental health and illness, psychology continues to be the leading discipline receiving National Institute of Mental Health (NIMH) research support. Future behavioral science research initiatives at NIMH are likely to emphasize cognitive science, behavioral genetics, behavioral patterns and physiological systems, and personality, motivation, emotion, and interpersonal processes. Although prognostication is particularly risky in times of transition such as the present, advocacy efforts focused on mental-illness-related research are most likely to help the NIMH and the field if they avoid polarization and factionalization by providing equal encouragement for studies of biological aspects, of behavioral aspects, and of their interaction.     

Overview of NIMH support of research in behavior therapy

Many parts of the National Institute of Mental Health have explicit policies of encouraging research on behavior therapy. The policies about behavior therapy research of sub-units of NIMH are reviewed, as these policies existed in fiscal year 1973. Examples are given of the type of behavior therapy research that NIMH was supporting in 1972. Particularly important is the evaluation of the efficacy of behavior therapy in comparison with standard treatment procedures.     

Control groups in psychosocial intervention research: ethical and methodological issues

This article summarizes a National Institute of Mental Health (NIMH) workshop that was convened to address the ethical and methodological issues that arise when conducting controlled psychosocial interventions research and introduces 6 thoughtful and inspiring papers presented by workshop participants. These papers, on topics ranging from informed consent to ethnic minority issues, reflect the depth and breadth of expertise represented by the multidisciplinary group of scientists and ethicists present at the meeting. More extensive follow-up, particularly from federal research applications and publications, of how investigators balance the need for strong research design with ethical considerations may help advance the science of psychosocial intervention research.     

BASIC BEHAVIORAL SCIENCE RESEARCH FOR MENTAL HEALTH: A National Investment

Psychological Science is pleased to reprint this Executive Summary of a report written in response to a request by the Senate Committee on Appropriations that a national plan for behavioral science research be developed The authors of the report, the Behavioral Science Task Force of the National Advisory Mental Health Council, included 52 eminent behavioral and social scientists in the field as well as staff of the Division of Neuroscience and Behavioral Science of the National Institute of Mental Health (NIMH) (see the list of contributors at the end of the Executive Summary) To receive a complete copy of the report, write to the Behavioral, Cognitive, and Social Sciences Research Branch, NIMH, 5600 Fishers Lane Room 11C-16, Rockville, MD 20857, e-mail: behavsci@helix.mh.gov     

Some nontraditional (Unconventional and/or innovative) sychosocial treatments for children and adolescents: Critique and proposed screening principles

Five examples of nontraditional psychosocial treatments used for children/adolescents are reviewed: eye movement desensitization and reprocessing, electroencephalographic (EEG) biofeedback, deep pressure/touch therapies, stress-challenge treatments, and confrontational scare treatments. The generic recommendations from the September 1992 National Institutes of Health Conference on Unconventional Medical Treatments are summarized. Additional screening principles specific for psychosocial treatments are proposed and applied to the five treatments. The screens do not validate treatment efficacy or evaluate the quality of any previous research, but only facilitate decisions as to whether treatments deserve controlled investigation. Scientific evaluation of the nontraditional treatments reviewed could in general benefit from blinds (at least for assessment); control conditions matched for intensity, frequency, and duration (double blind where feasible); dose-response studies; testing of generalization and endurance supplements or boosters for quick, cheap treatments with time- or domain-limited effects; and comparing cost-effectiveness with established treatments. Two unscientific pitfalls must be avoided: embracing new treatments uncritically and rejecting them without fair examination. These pitfalls must be skirted without dissipating scarce research resources.The views and proposals in this article are those of the author, and do not in any way reflect any official National Institute of Mental Health (NIMH) position. Further, mention or review of any particular treatment does not constitute endorsement of that treatment by either NIMH or the author.     

Mental health services for homeless mentally ill persons. Federal initiatives and current service trends

Recent research suggests that approximately one third of the population of homeless single adults suffer from severe mental illnesses. Despite multiple health, mental health, and social welfare needs, this population is often unable to obtain necessary housing and community-based services. For this reason, since 1982, the National Institute of Mental Health (NIMH) has undertaken a number of federal initiatives to encourage research and assist states and localities in improving services focused on this vulnerable subgroup of the homeless population. This article describes the target population, NIMH research findings, and current mental health service trends--with particular emphasis on two mental health programs established under the Stewart B. McKinney Homeless Assistance Act. Proposed future directions for federal research and evaluation efforts in this area are also discussed.     

A comparative evaluation of parent-training interventions for families of chronic delinquents

Fifty-five families of chronically offending delinquents were randomly assigned to parent-training treatment or to service traditionally provided by the juvenile court and community. The families in the parent-training group received an average of 44.8 hours of professional contact (23.3 hours of which were phone contacts), and each control group family received treatment estimated at more than 50 hours on the average. Comparisons of police contact data at baseline and subsequent years for the two groups showed that subjects in both groups demonstrated reduced rates of offending during the followup years. The finding most relevant was significant treatment-by-time effect for offense rates, with most of this effect accounted for by a greater reduction in serious crimes for the experimental group during the treatment year, and a similar reduction of the community control group occurring in the first of three followup years. These early decrements in offense rates persisted during followup for both groups. Throughout the study, boys in the experimental group spent significantly less time in institutional settings than did boys in the control group. Parent training had a significant impact, but the reduction in offending was produced at very high emotional cost to staff. Although it is clear that this population requires substantial treatment resources, this study underscores the need for more work on prevention.Research for this paper was supported by grant MH 37938 from the Center for Studies of Antisocial and Violent Behavior, National Institute of Mental Health (NIMH), U.S. Public Health Service (PHS). The writing was supported in part by grants MH 17126 and MH 37940 from the same Center, grant DA 05304 from the National Institute of Drug Abuse, U.S. PHS., and grant MH 38730 from the Child and Adolescent Disorders Research Branch, NIMH, U.S. PHS. The authors gratefully acknowledge the enduring commitment of the treatment staff that made this study possible: Patricia Chamberlain, Marion Forgatch, and Kate Kavanagh.     

Self- and interview-rated negative mood states in schizophrenia: Their convergence and prediction of thought disturbance

This longitudinal study evaluated the relations between self- and interview-rated negative mood in schizophrenics and compared the prognostic utility of these two methods. Thirty schizophrenics who had been stabilized on neuroleptic medications were evaluated with self-report and interview-based measures of mood and symptomatology at an initial assessment and again at 6-month follow-up. Results indicated that measures of self- and interview-rated negative mood showed little agreement at the initial assessment; however, at follow-up, significant convergent correlations between the two methods were obtained. Self-reported negative mood at the initial evaluation predicted the severity of thought disturbance at follow-up, whereas interview-based ratings of mood did not. The results underscore the importance of conducting multimethod assessments of mood and support other research suggesting that self-reported negative mood states may predict course of the illness in schizophrenia.This research was supported by National Institute of Mental Health (NIMH) Grants MH38636 and MH39998 and by a grant from the National Alliance for Research in Schizophrenia and Depression (NARSAD). Jack J. Blanchard was also supported in part by NIMH Grant MH18932 for the Collaborative Training Program in Schizophrenia Research at the Medical College of Pennsylvania/EPPI. Portions of this research were presented at the 24th Annual Meeting of the Association for the Advancement of Behavior Therapy, San Francisco, California, November 2, 1990, and at the 3rd International Congress on Schizophrenia Research, Tucson, Arizona, April 22, 1991.     

Mental health status among Puerto Ricans,Mexican Americans,and Non-Hispanic whites

Compared mental health characteristics of island Puerto Ricans to three groups from the Los Angeles Epidemiologic Catchment Area Study: Mexican American immigrants, U.S.-born Mexican Americans, and Non-Hispanic whites. The Diagnostic Interview Schedule was used to obtain both diagnostic and symptom scale information about affective disorders, alcohol abuse/dependence, somatization, phobic disorder, and psychotic disorder. Mexican American immigrants had the fewest mental health problems of all groups. Puerto Ricans had more somatization disorder, but less affective and alcohol disorders than U.S-born Mexican Americans or non-Hispanic whites. Results are considered in the light of selection factors, relative disadvantage of groups and methodological problems. This research was supported by grants MH36230 and MH45763 from the National Institute of Mental Health, and made use of data from the Los Angeles site of the Epidemiologic Catchment Area Program, which is a series of five epidemiologic research studies performed by independent research teams in collaboration with staff of the Division of Biometry and Epidemiology of the National Institute of Mental Health. The NIMH principal collaborators were D. Regier, B. Locke, W. Eaton and J. Burke. The NIMH project officers were C. Taube and W. Huber. The principal investigators and coinvestigators from the five sites were Yale University: J. Myers, M. Weissman, G. Tischler; Johns Hopkins University: M. Kramer, E. Gruenberg, S. Shapiro; Washington University: L. Robins, J. Helzer; Duke University: D. Blazer, L. George; University of California at Los Angeles: M. Karno, R. Hough, J. Escobar, A. Burnam, D. Timbers.     

Severity of unipolar depression and choice of treatment.

The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (Elkin et al., Archives of General Psychiatry, 46, 971-982; 1989) reported treatment-by-severity interactions favouring pharmacotherapy for more depressed outpatients, on a minority of relevant comparisons. The present study reports secondary analyses from a similar, preexisting data set in which treatment-by-severity interactions are systematically investigated with depressed outpatients treated either with nondirective psychotherapy, behaviour therapy, pharmacotherapy, or relaxation/placebo. Despite multiple severity measures and variable severity cut scores, no treatment was differentially effective in improving more severely depressed patients. Also, there was little difference across symptom severity levels in the proportions of recovered patients between treatment groups. Finally, dynamic cluster analysis demonstrated that the proportion of pharmacotherapy nonresponders (20%) did not differ from the proportion of nonresponders in behaviour therapy or placebo groups. It is concluded that this failure to replicate the NIMH trial findings can not be attributed to treatment differences, populations or statistical power. The suggestion that pharmacotherapy be the treatment of choice for more severely depressed outpatients appears to be unjustified on the basis of available evidence.     

Eating disorders: National Institute of Mental Health's perspective

The mission of the National Institute of Mental Health (NIMH) is to reduce the burden of mental and behavioral disorders through research, and eating disorders embody an important fraction of this burden. Although past and current research has provided important knowledge regarding the etiology, classification, pathophysiology, and treatment of the eating disorders, there are still significant challenges that need to be addressed. This article briefly describes some of these challenges, recent NIMH-supported research and research-related activities directed at addressing these challenges, and approaches and areas of research that hold promise for furthering the understanding and treatment of eating disorders.     

Responses to Conflict and Cooperation in Adolescents with Anxiety and Mood Disorders

This study examined patterns of behavioral and emotional responses to conflict and cooperation in adolescents with anxiety/mood disorders and healthy peers. We compared performance on and emotional responses to the Prisoner’s Dilemma (PD) game, an economic exchange task involving conflict and cooperation, between adolescents with anxiety/depressive disorders (A/D) (N=21) and healthy comparisons (n = 29). Participants were deceived to believe their co-player (a pre-programmed computer algorithm) was another study participant. A/D adolescents differed significantly from comparisons in patterns of play and emotional response to the game. Specifically, A/D participants responded more cooperatively to cooperative overtures from their co-players; A/D girls also reported more anger toward co-players than did comparison girls. Our findings indicate that A/D adolescents, particularly females, respond distinctively to stressful social interchanges. These findings offer a first step toward elucidating the mechanisms underlying social impairment in youth with internalizing disorders. This research was supported by the Intramural Research Program of the NIH, NIMH.     

The schizophrenic diathesis and the kibbutz

In this article, the National Institute of Mental Health (NIMH) "Israeli High Risk Study," which extended over two decades and compared the relative effects of kibbutz and city environments on the diathesis of schizophrenia, is critically examined. Comparison data on personality and cognitive functions of groups of 11- to 16-year-olds and adults are reviewed in the light of previously published material. The apparent shifts in level of adjustment of kibbutz and city subjects, as well as the allegedly greater incidence of pathology in the kibbutz index group, are questioned on methodological grounds.     

Principles versus procedures in making health care coverage decisions: addressing inevitable conflicts

It has been suggested that focusing on procedures when setting priorities for health care avoids the conflicts that arise when attempting to agree on principles. A prominent example of this approach is “accountability for reasonableness.” We will argue that the same problem arises with procedural accounts; reasonable people will disagree about central elements in the process. We consider the procedural condition of appeal process and three examples of conflicts over coverage decisions: a patients’ rights law in Norway, health technologies coverage recommendations in the UK, and care withheld by HMOs in the US. In each case a process is at the center of controversy, illustrating the difficulties in establishing procedures that are widely accepted as legitimate. Further work must be done in developing procedural frameworks. The opinions expressed are the authors’ own. They do not reflect any position or policy of the National Institutes of Health, US Public Health Service, or Department of Health and Human Services. This research was supported by the Intramural Research Program of the NIH Clinical Center.     

Child and adolescent psychopathology research: Problems and prospects for the 1990s

In November 1990 the National Institute of Mental Health (NIMH) convened a special conference of over 100 scientists and leaders to outline specific strategies and research initiatives that should be developed to implement the recently released National Plan for Research on Child and Adolescent Mental Disorders.Participants included journal editors, educators from psychology and psychiatry, representatives from private foundations, and leaders of research program areas in public funding agencies. Critical knowledge gaps were identified in five areas of child and adolescent psychopathology, including depression, attention deficit hyperactivity disorder, conduct disorder, the anxiety disorders, and the developmental disorders. For each of these areas, special emphasis was placed on developing new ideas and obtaining critical input from other areas of investigation. This report summarizes the identified research gaps and recommends research initiatives to implement the National Plan, as outlined by the conference participants.     

The Schizophrenic Diathesis and the Kibbutz

In this article, the National Institute of Mental Health (NIMH) "Israeli High Risk Study," which extended over two decades and compared the relative effects of kibbutz and city environments on the diathesis of schizophrenia, is critically examined. Comparison data on personality and cognitive functions of groups of 11- to 16-year-olds and adults are reviewed in the light of previously published material. The apparent shifts in level of adjustment of kibbutz and city subjects, as well as the allegedly greater incidence of pathology in the kibbutz index group, are questioned on methodological grounds.     

Empirically defined symptom scales using the DISC 2.3

Empirically defined scales of depressive, attention deficit hyperactivity disorder, oppositional-defiant disorder, and conduct symptoms from the lay-administered National Institute of Mental Health (NIMH) Diagnostic Interview Schedule for Children (DISC), version 2.3, and evidence of their reliability and validity, are presented. The scales were developed using factor analyses of data obtained from an epidemiologic survey of over 1,200 children drawn from four sites across the U.S. and Puerto Rico (the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders, or MECA Study). Their psychometric properties were tested in a subsample of children reinterviewed by clinicians. The findings support the use of these continuous measures. The scales are strongly related to the diagnostic categories and show good test-retest reliability. The scales can be used to characterize severity in children with diagnoses and to describe problems and symptoms in children without diagnoses. Because these scales can measure gradations in symptomatology, they may be more useful than categorical measures. Like categorical measures, the scales based on the DISC are greatly influenced by the informant, whether child or parent.This research was supported by grant MH-46732 from the National Institute of Mental Health, Bethesda, Maryland.The MECA Program is an epidemiologic methodology study performed by four independent research teams in collaboration with staff of the Division of Clinical Research, which was reorganized in 1992 with components now in the Division of Epidemiology and Services Research and the Division of Clinical and Treatment Research, of the NIMH, Rockville, Maryland. The NIMH Principal Collaborators are Darrel A. Regier, MD, MPH, Ben Z. Locke, MSPH, Peter S. Jensen, MD, William E. Narrow, MD, MPH, and Donald S. Rae, MA; the NIMH Project Officer was William J. Huber. The Principal Investigators and Coinvestigators from the four sites are as follows: Emory University, Atlanta, Georgia, UO1 MH46725: Mina K. Dulcan, MD, Benjamin B. Lahey, PhD, Donna J. Brogan, PhD, Sherryl Goodman, PhD, and Elaine Flagg, PhD; Research Foundation for Mental Hygiene at New York State Psychiatric Institute (Columbia University), New York, New York, UO1 MH46718: Hector R. Bird, MD, David Shaffer, MD, Myrna Weissman, PhD, Patricia Cohen, PhD, Denise Kandel, PhD, Christina Hoven, PhD, Mark Davies, MPH, Madelyn S. Gould, PhD, and Agnes Whitaker, MD; Yale University, New Haven, Connecticut, UO1MH46717: Mary Schwab-Stone, MD, Philip J. Leaf, PhD, Sarah Horwitz, PhD, and Judith H. Lichtman, MPH; University of Puerto Rico, San Juan, Puerto Rico, UO1 MH46732: Glorisa Canino, PhD, Maritza Rubio-Stipec, MA, Milagros Bravo, PhD, Margarita Alegría, PhD, Julio Ribera, PhD, Sarah Huertas, MD, and Michael Woodbury, MD.The authors gratefully acknowledge Zenaida González and José Martínez who performed the data nalayses, as well as Elizabeth Pastrana, and Felícita Laboy, secretaries, for their valuable contributions to this work.