RESEARCH ON MENTAL HEALTH SERVICES IN GENERAL HEALTH CARE

NIH GUIDE, Volume 21, Number 32, September 4, 1992



PA NUMBER:  PA-92-103



P.T. 34



Keywords:

  Mental Disorders 

  Health Services Delivery 



National Institute of Mental Health



PURPOSE



The goal of this Program Announcement (PA) is to encourage research on

mental disorders in primary care and other general medical settings,

particularly research that focuses on the nature, recognition,

classification, treatment, and outcomes of people with mental disorders

in these service settings.  This announcement may encourage the

development of needed research that seeks to improve understanding of

how best to assess mental disorders and provide mental health services

in general health care settings.



Among people with current mental disorders who use health services,

about half are not treated in the specialty mental health care sector

and receive health services only in general medical settings.  While

investigator-initiated research in this area has grown substantially,

there is still a tremendous dearth of accurate information on the kinds

of patients with mental disorders in the general health care sector,

the nature and severity of their disorders, and the relationship of

these mental disorders to medical conditions, as well as on the mental

health services--- types, quality, effectiveness---delivered in primary

care and other general health care sectors (e.g., emergency rooms,

nursing homes, general hospital medical and surgical units,

rehabilitation hospitals).



The Primary Care Research Program at the National Institute of Mental

Health (NIMH) was established in response to research findings

indicating the relative gap in use of specialty mental health services

compared to primary care service use by people with mental disorders,

and as an attempt to understand the low recognition rates of mental

disorders in general medical settings and to contribute to health care

policy.  While major research issues at the outset included

epidemiological (prevalence and types of disorders), nosologic

(validity and reliability of diagnoses), clinical practice and

services, systems/organizational, and economic questions, existing

research data are still scant in most of these areas, despite a growth

in the field's scientific inquiries and related activities sponsored by

the program.  Furthermore, this research is called for by the mental

health objectives in the recent report "Healthy People 2000"---two of

which directly address the provision of mental health services by

primary care providers (6.13, 6.14) [footnote 1].  Other recent

activities---the Agency for Health Care Policy and Research of

guidelines for the treatment of depression in primary care (with which

the NIMH has been involved) [footnote 2] active work with new

classification of mental disorders in primary care [footnote 3]---

support this effort.



These and other activities [footnote 4], aligned with scientific data

on the impact of mental health on overall functioning and disability in

people seen in the general health care sector [footnote 5] make a

strong call for more scientific inquiry to inform the gaps between the

mental health needs seen in these general sector settings and the

services provided in these settings.



These gaps are even more evident in special populations seen mainly in

the general health care sector and the special issues of access,

assessment, and utilization that are unique to them:  rural groups,

minority populations, inner city groups, and HIV-infected people.

Attention should also be given to unique issues related to women,

children, adolescents, and the elderly.



Last, research is strongly needed on those people with mental disorders

who may need more services in the general health sector, particularly

the severely mentally ill [footnote 6] and the homeless.



HEALTHY PEOPLE 2000



The Public Health Service (PHS) is committed to achieving the health

promotion and disease prevention objectives of "Healthy People 2000,"

a PHS-led national activity for setting priority areas.  This effort is

in accordance with specific objectives 6.13 and 6.14.  Potential

applicants may obtain a copy of "Healthy People 2000" (Full Report:

Stock No. 017-001-00474-0 or Summary Report:  Stock No.

017-001-00473-1) through the Superintendent of Documents, Government

Printing Office, Washington, DC 20402-9325, telephone (202) 783-3238.



ELIGIBILITY REQUIREMENTS



Applications may be submitted by foreign and domestic, public and

private, non-profit and for-profit organizations, such as universities,

colleges, hospitals, laboratories, units of State and local

governments, and eligible agencies of the Federal Government.  Women

and minority investigators are encouraged to apply.  Foreign

institutions are only eligible for traditional research grants.



MECHANISMS OF SUPPORT



Research support may be requested through applications for traditional

research grant (RO1), a small grant (R03), and First Independent

Research Support and Transition (FIRST) Award (R29).  Since the latter

programs have special requirements, applicants are advised to refer to

specialized announcements for the small grant and FIRST award programs,

available from:



National Institute of Mental Health

Division of Extramural Activities

Office of Extramural Policy and Analysis

5600 Fishers Lane, Room 9-97

Rockville, MD  20857

Telephone:  (301) 443-4673



Terms and Conditions of Support



Grant funds may be used for expenses clearly related and necessary to

conduct the proposed research, including direct costs and allowable

indirect costs.



Period of Support



Applications for traditional research projects may request support for

up to five years.  Small grants are limited to two years and may not be

renewed.  FIRST awards are made for five years, but are not renewable.

Annual awards will be made, subject to continued availability of funds

and progress achieved.  A competing continuation (renewal) application

for a traditional research award (RO1) may be submitted before the end

of an approved period of support in order to request funds for the

continuation of the project.



RESEARCH OBJECTIVES



The following list of research objectives is meant to be exemplary and

not exhaustive---it serves to identify key topics in which further

rigorous scientific research is needed to delineate mental health needs

and to assess the mental health services provided in the general health

care sector:



(1) Methodological Issues



o  Studies of classification systems for mental disorders and

treatments delivered in the general health care sector, with special

emphasis on validity, comparative diagnostic assessments, and clinical

problems not addressed by available nosologic systems (e.g., childhood

behavioral disorders, subsyndromal disorders like minor depression or

mixed anxiety-depression)



o  Research on the development, applicability, and utility of

instruments or analytic techniques that may be used to assess

multi-dimensional outcomes for people with both mental and medical

disorders seen in the general health care sector.  Such outcomes might

include severity of illness, disability, costs, and community and

family burden



o  Research on the applicability and utility of existing mental health

screening, diagnostic and management instruments in primary care

settings, particularly among patients from different socio-economic,

ethnic, and cultural backgrounds



o  Studies using innovative methodologies (e.g., decision analysis,

meta-analysis) to examine the clinical management of people with mental

disorders in the general health care sector



(2) Recognition and Diagnosis



o  Studies examining the presentation and nature of mental disorders in

primary care and other general health care settings (especially for

children and the elderly), especially duration, remission, and

recurrence of these disorders, with special consideration to the

longitudinal evaluation of treated and untreated subsyndromal

conditions that impair health status



o  Studies of the impact of co-occurring general medical illnesses on

the accurate assessment of mental disorders, and impact on mental

health services delivered in the general health sector for these

populations (e.g., the "accurate" assessment of depression in the

medically ill and service implications)



o  Studies of the relationship between co-occurring alcohol or drug

problems and mental disorders, and the impact of these conditions on

accurate recognition of mental problems by general health care

providers



o  Studies of the barriers to the accurate recognition and diagnosis of

mental disorders, especially in primary care, with special attention to

(a) patient variables such as population specific beliefs (e.g., rural,

cultural) and (b) provider variables, such as knowledge and attitudes

about mental disorders, which may impact on recognition and management

of people with mental disorders



(3) Clinical Services and Practices



o  Research on the types, quality and effectiveness of mental health

services provided by general health care providers, differences of

these services in relation to type of patient (e.g., understudied

groups like the elderly and women in various life cycle stages who seek

general health care), provider (e.g., physician, nurse, social worker)

and setting, and impact on patient outcomes



o  Studies of referral patterns from the general health care sector to

the mental health care sector and barriers to referral (e.g., access,

attitudes, training, reimbursement)---rates, processes, and effect on

patient outcomes, as well as strategies to overcome those barriers



o  Studies addressing improvement of current clinical practice to

ensure adequate mental health services in the general health care

sector---application of clinical trials, analysis of provider-patient

interactions, feasibility of transferring specialist mental health

services to general health care settings, and consultation-liaison

models



o  Studies of innovative educational/teaching models to improve the

recognition and care of patients with mental disorders by their general

health care service providers (e.g., utility of clinical practice

guidelines)



(4) Service System and Financing Issues



o  Studies of the organization, delivery, and cost-effectiveness of

services for mental conditions in primary care settings, with focus on

variations in practice (e.g., managed care systems) and setting (e.g.,

rural, community health centers)



o  Research on the impact of different reimbursement approaches on the

use of general health vs. mental health services (e.g., prepaid health

plans) and implications for services, quality of care, and patient

outcomes



o  Research on existing or innovative models linking or integrating

mental health services with the general health care sector,

particularly for people with severe mental disorders and/or who are

homeless, whose needs crosscut different systems of care (e.g., state

consolidated funding for continuous, coordinated health and social

services)



o  Studies examining the nature and effectiveness of relationships

between the general health care sector and other systems (e.g.,

educational, legal, community) in providing mental health services



STUDY POPULATIONS



Protection of Human Subjects



The Department of Health and Human Services has regulations for the

protection of human subjects and has developed additional regulations

for the protection of children.  A copy of these regulations (45 CFR

46, Protection of Human Subjects) and those pertaining specifically to

children are available from the Office for Protection from Research

Risks, National Institutes of Health, Bethesda, MD 20892, telephone

(301) 496-7041.  Specific questions concerning protection of human

subjects in research may be directed to NIMH staff members listed under

INQUIRIES.



NIH POLICY CONCERNING INCLUSION OF MINORITIES AND WOMEN AS SUBJECTS IN

RESEARCH



Applications for grants and cooperative agreements that involve human

subjects are required to include minorities and both genders in study

populations so that research findings can be of benefit to all persons

at risk of the disease, disorder or condition under study; special

emphasis should be placed on the need for inclusion of minorities and

women in studies of diseases, disorders and conditions which

disproportionately affect them.  This policy applies to all research

involving human subjects and human materials, and applies to males and

females of all ages.  If one gender and/or minorities are excluded or

are inadequately represented in this research, particularly in proposed

population-based studies, a clear compelling rationale for exclusion or

inadequate representation should be provided.  The composition of the

proposed study population must be described in terms of gender and

racial/ethnic group, together with a rationale for its choice.  In

addition, gender and racial/ethnic issues should be addressed in

developing a research design and sample size appropriate for the

scientific objectives of the study.



Applicants are urged to assess carefully the feasibility of including

the broadest possible representation of minority groups.  However, the

NIH recognizes that it may not be feasible or appropriate in all

research projects to include representation of the full array of United

States racial/ethnic minority populations (i.e., American Indians or

Alaskan Natives, Asians or Pacific Islanders, Blacks, Hispanics).

Investigators must provide the rationale for studies on single minority

population groups.



Applications for support of research involving human subjects must

employ a study design with minority and/or gender representation (by

age distribution, risk factors, incidence/prevalence, etc.) appropriate

to the scientific objectives of the research.  It is not an automatic

requirement for the study design to provide statistical power to answer

the questions posed for men and women and racial/ethnic groups

separately; however, whenever there are scientific reasons to

anticipate differences between men and women, and racial/ethnic groups,

with regard to the hypothesis under investigation, applicants should

include an evaluation of these gender and minority group differences in

the proposed study.  If adequate inclusion of one gender and/or

minorities is impossible or inappropriate with respect to the purpose

of the research, because of the health of the subjects, or other

reasons, or if in the only study population available, there is a

disproportionate representation of one gender or minority/majority

group, the rationale for the study population must be well explained

and justified.



The NIH funding components will not make awards of grants and

cooperative agreements that do not comply with this policy.  For

research awards which are covered by this policy, awardees will report

annually on enrollment of women and men, and on the race and ethnicity

of subjects.



APPLICATION PROCEDURES



Applicants are to use the Public Health Service research grant

application form PHS 398 (rev. 9/91).  The number and title of this

announcement, PA-92-103, Research on Mental Health Services in the

General Health Care Sector, must be typed in item number 2a on the face

page of the PHS 398 application form.



Application kits containing the necessary forms may be obtained from

business offices and offices of sponsored research at most

universities, colleges, medical schools, and other major research

facilities.  If such a source is not available, the following office

may be contacted for the necessary application material:



Grants Management Branch

National Institute of Mental Health

5600 Fishers Lane, Room 7C-05

Rockville, MD  20857

Telephone:  (301) 443-4414



The signed original and five legible copies of the completed

application must be sent to:



Division of Research Grants

National Institutes of Health

Westwood Building, Room 240

Bethesda, MD  20892**



REVIEW CONSIDERATIONS



Applications will be reviewed for scientific and technical merit by the

assigned review group in accordance with the standard NIH peer review

procedures.  Following scientific-technical review, the applications

will receive a second-level review by the appropriate national advisory

council.



Review criteria include:



o  Scientific, technical, or medical significance and originality of

the proposed research;



o  Appropriateness and adequacy of the experimental approach and

methodology proposed to carry out the research;



o  Qualifications and research experience of the Principal Investigator

and staff, particularly but not exclusively in the area of the proposed

research;



o  Availability of resources necessary to perform the research, and



o  Appropriateness of the proposed budget and duration in relation to

the proposed research.



Applications will be reviewed in accordance with the following review

schedule:



Receipt Dates    Initial   Advisory Council   Earliest

New/Renewal      Review        Review         Start Date



Feb 1/Mar 1*     May/Jun      Sep/Oct         Dec 1

Jun 1/Jul 1*     Oct/Nov      Jan/Feb         Apr 1

Oct 1/Nov 1*     Feb/Mar      May/Jun         Jul 1



*Competing continuations, supplemental, and revised applications are to

be submitted on these dates.



Applications received after a given receipt date will be held for the

next scheduled receipt date or returned to the applicant, if so

requested by the applicant, without review.



AWARD CRITERIA



Applications will compete for available funds with all other approved

applications.  The following will be considered in making funding

decisions:  quality of the proposed project as determined by peer

review, availability of funds, and program balance among research areas

of the announcement.



INQUIRIES



NIMH staff are available for consultation concerning application

development before or during the process of preparing an application.

Potential applicants are advised to contact NIMH staff as early as

possible for information and assistance in initiating the application

process and developing an application.



Direct inquiries regarding programmatic issues to:



Junius J. Gonzales, M.D.

Chief, Primary Care Research Program

Services Research Branch

Division of Applied and Services Research

National Institute of Mental Health

5600 Fishers Lane, Room 18C-14

Rockville, MD  20857

Telephone:  (301) 443-1330



Direct inquiries regarding fiscal matters to:



Stephen J. Hudak

Chief, Grants Management Section

National Institute of Mental Health

5600 Fishers Lane, Room 7C-23

Rockville, MD  20857

Telephone:  (301) 443-4456



AUTHORITY AND REGULATIONS



This program is described in the Catalog of Federal Domestic Assistance

No. 93.242.  Awards are made under authorization of the Public Health

Service Act, Title IV, Part A (Public Law 78-410, as amended by Public

Law 99-158, 42 USC 241 and 285) and administered under PHS grants

policies and Federal Regulations 42 CFR 52 and 45 CFR Part 74.

Applications submitted in response to this announcement are not subject

to the intergovernmental review requirements of Executive Order 12372

or Health Systems Agency review.



FOOTNOTES



1.  Healthy People 2000, DHHS Publication No. (PHS) 91- 50212.

Potential applicants may obtain a copy of Healthy People 2000 (Full

Report:  Stock No. 017-001-00474-0 or Summary Report:  Stock No.

017-001-00473-1) through the Superintendent of Documents, Government

Printing Office, Washington, DC 20402-9325 (telephone:  (202)

783-3238).



2.  AHCPR Panel on Guidelines for the Treatment of Depression in

Primary Care.



3.  NIMH Workshops on the Classification of Mental Disorders in Primary

Care, 1989-90.



4.  Primary Care Research:  Theory and Practice, Conference

Proceedings, Agency for Health Care Policy and Research Publication No.

91-011.



5.  Wells KB et al.  The functioning and well-being of depressed

patients: Results from the medical outcomes study.  Jour. Amer. Med.

Assoc. 262: 914-919, 1989.



6.  Caring for People With Severe Mental Disorders:  A National Plan of

Research to Improve Services, DHHS Publication No. (ADM) 91-1762.



.

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