National Advisory Mental Health Council Research Articles

Anhedonia in Nicotine Dependence.

Prior findings indicate that trait anhedonia enhances the likelihood of becoming a tobacco smoker, and preliminary evidence suggests that smoking abstinence leads to anhedonic states in some individuals and situations, and nicotine administration reduces anhedonic states. Nevertheless, many vital questions exist concerning relationships between anhedonia and nicotine dependence, including situational and individual difference factors that may moderate the strength of these associations. This chapter provides a critical review of the literature assessing relationships of anhedonia to nicotine dependence and the effects of acute nicotine through the lenses of the Research Domain Criteria's (RDoC) Positive Valence Systems (NIMH, RDoC changes to the matrix (CMAT) workgroup update: proposed positive valence domain revisions. A report by the national advisory mental health council workgroup on changes to the research domain criteria matrix, 2018) and the Situation x Trait Affective Response (STAR) model of nicotine's effects and nicotine dependence (Gilbert, Smoking individual differences, psychopathology, and emotion. Taylor and Francis, Washington, DC, 1995; Gilbert, Hum Psychopharmacol Clin Exp 12:S89-S102, 1997). The effects of nicotine and nicotine withdrawal on subjective, behavioral, and brain indices vary across the three RDoC Positive Valences Systems (Reward Responsiveness, Reward Learning, and Reward Valuation) in a manner that supports the research and potential clinical utility of using RDoC criteria and the STAR model to guide research and clinical innovation. We provide a revision of the STAR model that incorporates the three RDoC Positive Valence Systems with evidence that nicotine's effects on hedonic and affective processes vary as a function of the dominance/salience of (1) situational hedonic and affective cues and task/active coping cues, and (2) state executive functioning level/capacity and state reward sensitivity such that these effects of nicotine are maximal during states of suboptimal cognitive functioning and reward sensitivity, combined with low situational stimulus salience and low task-related cues/demands.

The rise and fall of the “warrior gene” defense

Since a 1993 study suggested that a single gene might predispose an individual to violence ([ 1 ][1]), criminal defendants have argued that their genes made them commit the crime. Through genome-wide association studies, we now understand that thousands of gene variants each contribute a very small amount to behavioral variation between individuals, and the idea that a single gene could cause violent behavior has been rejected. In February, the so-called “warrior gene” theory as a criminal defense was dealt a blow by the New Mexico Supreme Court in the case of State v. Yepez ([ 2 ][2]), but the ruling did not go far enough. By failing to address the current scientific consensus, the court missed an opportunity to create the much-needed persuasive authority for other courts on this issue. We must improve communication between scientists and the legal system to ensure that courts can access and understand the most current science. The defendant in the recent court case, Anthony Blas Yepez, sought to introduce expert testimony that he had a genetic predisposition to violence that prevented him from being able to form the intent necessary to commit second-degree murder. The trial court excluded the testimony—which linked Yepez's “warrior gene” and childhood maltreatment to his ability to form the intent to kill—as scientifically unproven. On appeal, the appellate court upheld his conviction but found that the trial court had acted wrongly in excluding the testimony ([ 3 ][3]). The New Mexico Supreme Court disagreed. It found that the trial court acted reasonably in excluding the testimony as scientifically unfounded. The New Mexico Supreme Court reached the right conclusion but used the wrong analysis. Their opinion ignored the scientific consensus, reached by 2011 and articulated in 2019 ([ 4 ][4]), which rejects a candidate-gene approach that identifies single genes responsible for variations in human behavior. The court wrongly endorsed the trial court's conclusion that findings from research like the original 1993 study had achieved “general acceptance…in the relevant scientific communities” ([ 2 ][2]). The court's mistake sets a dangerous legal precedent and threatens justice itself. The genetic predisposition defense has been used in other cases with starkly diverging results ([ 5 ][5]). Some defendants have been convicted on lesser charges, whereas others have been punished more harshly on the mistaken belief that the defendant was programmed to kill [e.g., ([ 6 ][6])]. This case could have set the record straight and established a precedent on which other courts could rely. We need better engagement between scientists, lawyers, and judges to help our legal institutions move beyond outdated science that wrongly labels defendants as genetically programmed to offend. 1. [↵][7]1. H. G. Brunner et al ., Science 262, 578 (1993). [OpenUrl][8][Abstract/FREE Full Text][9] 2. [↵][10] State v. Yepez , NO. S-1-SC-37216 C/W NO. S-1-SC-37217, 2021 WL 732668 (N.M. Supreme Court, 25 February 2021) 3. [↵][11] State v. Yepez , 428 P.3d 301 (Ct. App. New Mexico, 24 July 2018) 4. [↵][12]National Institute of Mental Health, “Report of the National Advisory Mental Health Council Workgroup on Genomics: Opportunities and challenges of psychiatric genetics” (2019); [www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/report-of-the-national-advisory-mental-health-council-workgroup-on-genomics.shtml][13]. 5. [↵][14]1. W. Bernet et al ., J. Foren. Sci. 52, 1362 (2007). [OpenUrl][15] 6. [↵][16] Schriro v. Landrigan , 550 US 465 (2007). G.E.R. served on the National Advisory Mental Health Council Workgroup on Genomics. [1]: #ref-1 [2]: #ref-2 [3]: #ref-3 [4]: #ref-4 [5]: #ref-5 [6]: #ref-6 [7]: #xref-ref-1-1 View reference 1 in text [8]: {openurl}?query=rft.jtitle%253DScience%26rft.stitle%253DScience%26rft.aulast%253DBrunner%26rft.auinit1%253DH.%26rft.volume%253D262%26rft.issue%253D5133%26rft.spage%253D578%26rft.epage%253D580%26rft.atitle%253DAbnormal%2Bbehavior%2Bassociated%2Bwith%2Ba%2Bpoint%2Bmutation%2Bin%2Bthe%2Bstructural%2Bgene%2Bfor%2Bmonoamine%2Boxidase%2BA%26rft_id%253Dinfo%253Adoi%252F10.1126%252Fscience.8211186%26rft_id%253Dinfo%253Apmid%252F8211186%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [9]: /lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6Mzoic2NpIjtzOjU6InJlc2lkIjtzOjEyOiIyNjIvNTEzMy81NzgiO3M6NDoiYXRvbSI7czoyMzoiL3NjaS8zNzEvNjUzNi8xMzIwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ== [10]: #xref-ref-2-1 View reference 2 in text [11]: #xref-ref-3-1 View reference 3 in text [12]: #xref-ref-4-1 View reference 4 in text [13]: http://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/report-of-the-national-advisory-mental-health-council-workgroup-on-genomics.shtml [14]: #xref-ref-5-1 View reference 5 in text [15]: {openurl}?query=rft.jtitle%253DJ.%2BForen.%2BSci.%26rft.volume%253D52%26rft.spage%253D1362%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [16]: #xref-ref-6-1 View reference 6 in text

Promise and Reality of Genomics: Link to Schizophrenia Involves Lots of Unknowns

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPromise and Reality of Genomics: Link to Schizophrenia Involves Lots of UnknownsMark MoranMark MoranSearch for more papers by this authorPublished Online:15 May 2017https://doi.org/10.1176/appi.pn.2017.5a1AbstractHundreds of possible gene mutations may act alone or with each other to determine phenotypic expression of schizophrenia.Better treatments for schizophrenia rely on a more complete understanding of how genetic mutations alter the activity of neural circuits in patients with the disease. NIMH Director Joshua Gordon, M.D., says extremely large study cohorts are necessary to help prioritize targets for genetic research in schizophrenia. That’s the message National Institute of Mental Health (NIMH) Director Joshua Gordon, M.D., delivered to researchers and clinicians during a plenary lecture at the International Congress of Schizophrenia Research in San Diego in March. Gordon said the path forward for genomics and schizophrenia, though promising, is extraordinarily daunting: hundreds of potential gene mutations act through the same complex chain—genes to molecules to cells to circuits to behavior—resulting in a diversity of possible phenotypes. This wide range of phenotypes accounts for what has traditionally been called the “heterogeneity” of schizophrenia. “There is the promise of genetics, and there is the reality,” Gordon said at the meeting. “The reality is that there are hundreds of genes that contribute to subsyndromal or syndromal schizophrenia, and each one of these mutations has a very small effect size. There is a lot of biology [between the mutation and the phenotypic expression of disease] that we don’t understand. When you throw in environmental influences, it makes the complexity picture completely non-linear.”Gordon gave an example of how genetics contribute to understanding the differential phenotypic expression of schizophrenia based on his own work at Columbia University and the New York Psychiatric Institute prior to his becoming director of NIMH. He and colleagues focused on the 22q11 microdeletion, a tiny mutation in a portion of chromosome 22 known to be associated with schizophrenia and cognitive deficits. They found that mice bred with the 22q11 microdeletion took longer to learn a working memory task than those that did not have the mutation. Additional analyses suggested that the working memory impairments in the mice appear to be due to disrupted communication between the hippocampus and the prefrontal cortex, where spatial information is encoded in memory. Even further, Gordon and his long-time collaborator Joseph Gogos, M.D., Ph.D., were able to elucidate neurochemical abnormalities in the development of axons (the threadlike fibers from a neuron that transmit information to another neuron), which appear to account for disrupted communication between the hippocampus and prefrontal cortex. Gordon said this work illustrates how genetic mutations and the various behavioral phenotypes associated with schizophrenia can be linked to offer a more complete understanding of the neurobiology of the disorder. In this case, one phenotypic expression (impaired working memory) is associated with a genetic mutation (22q11) that is linked to cells and neural networks specifically associated with disrupted communication of information between two brain structures (the hippocampus and prefrontal cortex). Yet as elegant as it appears, Gordon said it almost certainly oversimplifies the true picture of what happens in schizophrenia. “The bigger problem is that it represents only a portion of what we know about schizophrenia genetics,” Gordon said, with hundreds of other possible gene mutations that may act alone or in concert with each other to determine phenotypic expression. What is necessary and what Gordon said he and other researchers hope to find is “critical convergence” of research findings—“where some significant amount of schizophrenia is explained by one common convergent pathophysiology.” For that, he said, it will be necessary to collect data on extremely large population cohorts to link genomics to phenotypes. That’s an enormous undertaking. Gordon said he has appointed the Workgroup on Genomics of the National Advisory Mental Health Council and charged it with answering the following questions: What are the best strategies for prioritizing genetic signals/genes for functional analyses?What are the best experimental and computational tools for investigating genetic risk factors?How can NIMH leverage diverse population-based cohorts to enable large-scale genomic discovery?How should dimensional phenotypes be used to further elucidate the genetic architecture of mental disorders?In the meantime, Gordon suggested the way forward toward better treatment of patients with schizophrenia is to leverage developing integrated care networks to make the treatments that exist—antipsychotic medication and evidence-based psychosocial therapies—available to patients in primary care. “But I deeply believe that in order to truly transform the efficacy of drug treatment for schizophrenia we need to understand the neurobiology of the disease,” he said. ■ ISSUES NewArchived

NIMH Updates Strategic Research Plan

Back to table of contents Previous article Next article Professional NewsFull AccessNIMH Updates Strategic Research PlanNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:11 May 2015https://doi.org/10.1176/appi.pn.2015.5b2AbstractThe plan emphasizes the importance of investing in the fundamental science of the brain and behavior while continuing to respond to urgent mental health needs.APA is encouraged by the new Strategic Plan for Research that was recently released by the National Institute of Mental Health (NIMH), calling it a timely and well-rounded strategy that pays attention to the importance of public health principles, methodological rigor, new technologies, and health services research.This new strategic plan, which updates the 2008 version, was developed to keep pace with the evolving landscape of mental health discoveries. Just in the past few years, the arena of mental health has seen a flurry of activity, such as the launch of the National Institute of Health’s ambitious BRAIN Initiative and the passage of the Mental Health Parity and Addiction Equity Act. This updated plan will guide NIMH’s research priorities over the next five years and, similar to its 2008 predecessor, is organized around four high-level strategic objectives:Define the mechanisms of complex behaviors. Chart mental illness trajectories to determine when, where, and how to intervene.Strive for prevention and cures. Strengthen the public health impact of NIMH-supported research.Carol Tamminga, M.D., says that deepening understanding of the cellullar and molecular mechanisms underlying brain function are key to NIMH’s updated plan.David Hathcox“A key element in this update is to direct scientists toward the cellular and molecular mechanisms that underlie how the brain works,” said Carol Tamminga, M.D. She chairs the Department of Psychiatry at the University of Texas Southwestern Medical Center and is also a member of NIMH’s National Advisory Mental Health Council (NAMHC), which reviewed and provided guidance on this new plan.“In the future, we expect to learn more about the disease process, make better diagnoses, and identify more drug targets, but at this time there is still much we don’t know about complex behaviors and behavioral diseases,” she told Psychiatric News. One such underexplored area is the exposome, or the range of environmental and social exposures a person experiences over the lifetime—whether parental upbringing, socioeconomic status, air quality, or the gut microbiome. While such exposures have been appreciated as important influences for conditions like posttraumatic stress disorder, recent work has uncovered that the exposome even affects disorders with a heavy biological basis like schizophrenia. While new boundaries like exposome research and the neural mapping being carried out by the BRAIN Initiative need support, they should not supersede the push for more effective pharmacological, neurological, and psychotherapeutic therapies, said APA CEO and Medical Director Saul Levin, M.D., M.P.A., as part of the Association’s official comments on the new plan.“The identification of new targets and biomarkers must be in parallel with treatment development,” Levin said. “Given that the burden of morbidity and mortality associated with mental illness in the United States is over $300 billion annually, all avenues of research must be vigorously pursued with NIMH leading on these fronts.”The strategic plan aims to balance the need for long-term investments in basic research with urgent mental health needs, explained NIMH Director Thomas Insel, M.D. To achieve this goal, the updated plan retains a strong focus toward health services research, improved delivery models, and partnerships that can improve the implementation of research advances.“Psychiatry needs research on how to maximize our ability to get the most out of our current treatments and research that opens vistas on designing better treatments, and this plan nicely balances those competing imperatives,” said James Potash, M.D., the Paul W. Penningroth Professor and Chair of Psychiatry at the University of Iowa and a member of APA’s Council on Research. “Of course, it is imperative that NIMH has the funding to carry out these critical objectives in our field, and APA and its members need to make sure the value of these far-ranging basic and clinical programs is supported,” Potash continued.This updated strategic plan was shaped with the help of a diverse community of stakeholders, including the NAMHC and the NIMH Alliance for Research Progress (composed of members from numerous foundations and advocacy groups representing people with mental illness). Additionally, the draft plan was made available for public comment for one month and received nearly 600 responses, including from APA. ■The NIMH Strategic Plan for Research can be accessed here. ISSUES NewArchived

New Program Combines Residency and Ph.D. Training

New Program Combines Residency and Ph.D. Training

Introduction to the STAR*D Special Section

Introduction to the STAR*D Special Section

Publication Bias and the Efficacy of Antidepressants

Publication Bias and the Efficacy of Antidepressants

A Historical Account of the Society for Social Work and Research: Presidential Perspectives on Advances in Research Infrastructure

The Society for Social Work and Research (SSWR) was founded in 1994 to provide a meeting ground and support organization for individual social workers who engage in research. Over its first 14 years, SSWR has grown from a modest-sized organization that hosted an initial conference to a large and influential force that sponsors a wildly successful yearly conference. SSWR's annual conference now showcases a portfolio of awards, including a travel scholarship for a doctoral student, a named lecture, and a very competitive abstract submission process. Funding for research by social workers has grown over the years, and SSWR, in association with the Institute for the Advancement of Social Work Research (IASWR), has become a regular provider of educational opportunities about funding sources. This article presents perspectives from the first seven presidents of the organization, who describe the growing richness and diversity of SSWR's membership and projects and the increasing visibility of research conducted by social workers. KEY WORDS: infrastructure; organization; research; SSWR ********** The Society for Social Work and Research (SSWR) was founded as a membership organization in 1994 to support social workers interested in research. To preserve the history of SSWR, this article presents sections contributed by the first seven presidents, each describing, often from a personal point of view, how their efforts helped to build the organization and to contribute to the current research infrastructure in social work. PRESIDENTIAL PERSPECTIVES Janet B. W. Williams, Founding President, 1994-1996 It was 1992. The National Institute of Mental Health (NIMH)Task Force Report on Social Work Research (1991) had just been presented to the National Advisory Mental Health Council of NIMH. The report clearly acknowledged the significance of social work research by recognizing the breadth of critical problems with which social work deals and the increasing need for all human services to demonstrate the effectiveness of the services they provide. This report provided the stimulus and led to the funding that supported the establishment in 1992 of the Institute for the Advancement of Social Work Research (IASWR). IASWR was created by five leading social work organizations: Baccalaureate Program Directors (BPD), National Association of Deans and Directors (NADD), Group for the Advancement of Doctoral Education (GADE), Council on Social Work Education (CSWE), and NASW. SSWR was conceived in direct response to the NIMH Task Force Report conclusion that [t]hroughout the profession there is insufficient organizational support for research development. As a research social worker who was not embedded in a school of social work, I had always felt somewhat professionally isolated and hungry for interaction with nay social work research colleagues. As a faculty member in a medical school department of psychiatry, I frequently attended conferences and meetings of research-oriented groups in psychiatry but knew of no similar groups in social work. Therefore, at a psychiatry research meeting shortly after the Task Force Report was issued, I discussed these thoughts with Dr. Alan Leshner, at the time the director of the National Institute on DrugAbuse (NIDA). He agreed to support the founding of such a group and to contribute to its first conference. In 1992, at an NIMH-sponsored conference in Washington, DC (Building Social Work Knowledge for Effective Mental Health Services and Policies), I presented a plan for a new membership organization that would provide social work researchers with a base: the Society for Social Work and Research (SSWFZ). At that conference, Betsy Vourlekis also presented a report on the development of the new IASWR, as she had been appointed head of the implementation committee. At the conclusion of the conference, Betsy approached me and asked if I would delay the initiation of efforts to establish a membership group until the new organizationally based IASWR was firmly off the ground. …

Psychiatrist Ensures Field Has International Focus

Psychiatrist Ensures Field Has International Focus

Medicaid Coverage of Newer Psychotropic Medication

Approximately 5 million people in the United States suffer from severe mental illnesses such s schizophrenia, bipolar disorder, major depression, and severe forms of panic and obsessive--compulsive disorders (National Advisory Mental Health Council, 1993). These mental illnesses can run a chronic course and disable the daily living activities of individuals. Of the many treatment approaches available for severe mental illness, pharmacotherapy or drug treatment first introduced in the 1950s has been the most helpful in ameliorating symptoms caused by such disorders. The newer psychotropic drugs introduced in the mid-1990s have especially been found to be more promising than the earlier traditional psychotropic drugs. The overall findings of the clinical trials completed on newer antipsychotics provide evidence that these drugs are more effective and have fewer side effects compared with the older antipsychotic drugs (McEvoy, 1998). Clinical trials completed with newer antidepressant drugs likewise reveal that these drugs are as effective as traditional antidepressants and are safer in terms of adverse side effects (Rush, 1998). However, these newer drugs cost more than the traditional drugs (Nightengale, Crumly, Liao, Lawrence, & Jacobs, 1998). The high cost has led many private and public insurance companies to impose restrictions that can limit access to these newer drugs. State Medicaid programs, facing budget crisis, also institute such cost containment policies. Medicaid covers people who are predominantly from a low-income group and individuals who receive Supplemental Security Income because of their disabilities. It also covers many people with mental illnesses who are unemployed and who have severe symptoms (U.S. Department of Health and Human Services, 1999). Medicaid, consequently, is an important source of health coverage for people who might benefit most from the newer psychotropic drugs, yet cannot afford them. This preliminary study thus explores the extent of coverage of newer psychotropic drugs under Medicaid. There are no studies available on Medicaid psychotropic drug coverage, and this is a first step in understanding the availability of such drugs for patients with severe mental illness. FEDERAL MEDICAID DRUG COVERAGE POLICIES A review of the federal Medicaid drug coverage policies can clarify the extent of influence that the federal and state programs have on drug coverage. According to the Social Security Amendments of 1965 (P.L. Law 89-97), federal Medicaid policies give states some flexibility to determine the range of optional services covered under Medicaid, including prescription drugs (Buchanan & Smith, 1994). For federal Medicaid matching funds to be available to states for covered outpatient drugs of a manufacturer, the manufacturer must enter into and have in effect a rebate agreement with the federal government (personal communication with M. Hazelwood, manager, Pharmacy and Ancillary Services Programs, Illinois Department of Public Aid, December 20, 2000). This national drug rebate program was created by the Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508) and has been in effect since 1991. All of the drugs (except for a short list of drugs, such as those to treat hair loss, weight loss, infertility, and smoking) of the manufacturers who sign these rebate agreements will be covered by the state Medicaid programs. On a quarterly basis, the federal Medicaid agency sends the states a list of the manufacturers who have entered the drug rebate program. Although state Medicaid programs do not have the flexibility to decide not to cover these drugs, states may choose to put drugs from rebating manufacturers on prior authorization (Buchanan & Smith), which is a restriction that requires obtaining permission for payment before prescription. In addition, the Tax Equity and Fiscal Responsibility Act of 1982 (P.L. 97-248) allows state Medicaid programs to charge recipients nominal copayments for most covered services (Buchanan & Smith, 1994). …

The NIMH Blueprint for Change Report: Research Priorities in Child and Adolescent Mental Health

The National Institute of Mental Health established a special subgroup of its National Advisory Mental Health Council to review major research findings on child and adolescent psychiatric disorders over the past decade and to recommend research priorities for the next decade. This Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment published its report, titled Blueprint for Change: Research on Child and Adolescent Mental Health, in August 2001, and several new research announcements reflecting these new directions have been issued since that time. This article summarizes the rationale for and background to the report, its major conclusions, and the reasons why interdisciplinary and translational approaches to research questions in child and adolescent mental health will help to maximize scientific advances.

More Data Confirm Affordability of Parity

More Data Confirm Affordability of Parity

APA Applauds Introduction Of Mental Health Parity Bill

Back to table of contents Previous article Next article Government NewsFull AccessAPA Applauds Introduction Of Mental Health Parity BillChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:6 Apr 2001https://doi.org/10.1176/pn.36.7.0005APA Medical Director Steven Mirin, M.D. (right), calls for an end to “the discrimination that denies adequate insurance coverage to people with mental illness” at a press briefing last month on a new parity bill. At left is Sen. Pete Domenici (R-N.M.), who is cosponsoring the bill with Sen. Paul Wellstone (D-Minn.).Pass comprehensive parity in 2001! That is the message that sponsors and supporters of a comprehensive mental illness parity bill are sending to Congress.“The Mental Health Equitable Treatment Act of 2001 says loudly and clearly to Congress and our nation that the time has come to end the discrimination that denies adequate insurance coverage to people with mental illness,” said APA Medical Director Steven Mirin, M.D., at a briefing last month on Capitol Hill.APA is a member of the Coalition for Fairness in Mental Illness Coverage, which strongly supports comprehensive parity. Other members are the American Managed Behavioral Healthcare Association, American Medical Association, American Psychological Association, Federation of American Hospitals, National Alliance for the Mentally Ill, National Association of Psychiatric Health Systems, and the National Mental Health Association.The bill, S 543, was introduced by Senators Pete Domenici (R.-N.M.) and Paul Wellstone (D-Minn.). It improves upon their landmark 1996 Mental Health Parity Act, which prohibits only annual and lifetime dollar limits on treatment for mental illness that are different from those for physical illnesses.The bill had 12 cosponsors at press time. If enacted, the new parity legislation would replace the 1996 law, which is due to sunset in September.The companion bill in the House of Representatives, the Mental Health and Substance Abuse Act (HR 162), was introduced in January by Rep. Marge Roukema (R-N.J.), which at press time had 60 cosponsors (Psychiatric News, February 2). Roukema was a sponsor of the 1996 Mental Health Parity Act.The General Accounting Office, the investigative arm of Congress, reported last year that the 1996 law was not having a significant impact on mental health benefits because of unanticipated loopholes. Group health plans found new ways to circumvent parity coverage of mental illness, including limiting the number of inpatient and outpatient days for mental health treatment.“While there may be adherence to the letter of the law, there are certainly violations of the spirit of the law,” said Domenici at the briefing. Group health plans continue to use discriminatory copays, deductibles, and coinsurance amounts for mental health treatment, he explained.The 2001 bills, unlike the 1996 parity law, do not exempt employers that show that their annual costs of compliance exceed 1 percent, according to the legislation.The National Advisory Mental Health Council estimated in a report to Congress last year that mental health parity should not increase premiums by more than 1 percent.The 2001 Senate bill also exempts employers with 25 or fewer employees rather than 50 or fewer, as in the 1996 law.Domenici and Wellstone introduced a similar mental health parity bill in 1999 that applied to the coverage of treatment for “severe biologically based mental illnesses.” The 2001 version applies to all mental illnesses and conditions in DSM-IV-TR or the latest DSM version.Wellstone commented that group health plans in the private sector are lagging behind those participating in the Federal Employee Health Benefits Plan (FEHBP), which implemented comprehensive parity in January. The parity bill is modeled on provisions for the FEHBP.Like the 1996 parity law, the bill would supercede only weaker state parity laws. There are currently about 33 state parity laws with about 15 modeled on the 1996 law, according to the National Alliance for the Mentally Ill.Although President George W. Bush signed a limited parity bill into law in 1998 in Texas as governor, it remains to be seen how supportive he will be of the federal parity bill.Wellstone was planning on introducing a substance abuse parity bill at press time.The text of both bills can be found on the Web at thomas.loc.gov by searching on the bill number, S 543 or HR 162. ▪ ISSUES NewArchived

Economic grand rounds: the costs of parity mandates for mental health and substance abuse insurance benefits.

Employer-sponsored health plans typically provide less coverage for mental health and substance abuse treatment than for medical or surgical treatment. The merits and costs of mandating parity, or equivalent coverage, for insurance benefits for mental health and substance abuse treatment have been a recent topic of significant public debate. This article presents cost estimates for a variety of comprehensive parity mandates, including parity for different diagnoses, benefit provisions, and types of health insurance delivery systems.

A Call for a Mental Health Services Research Agenda for Youth with Serious Emotional Disturbance

This paper proposes a research agenda on clinical interventions for youth with serious emotional disturbances (SED). A National Institute of Mental Health (NIMH) National Advisory Mental Health Council report on adults with severe mental disorders issued in 1991, led to a research plan and a significant expansion of services research for this adult population. A similar strategy is proposed for children, based on three assumptions: (1) there is a real need for effective treatment; (2) the timing is right; and (3) a small cadre of child clinical and clinical services researchers is prepared to pursue such research. Four topics provide the rationale for NIMH or another agency to commission an expert panel to: (1) conduct an evidence-based review of promising interventions; (2) assess quality indicators; (3) evaluate outcome measures; and (4) reach consensus on a research phase model. A research plan for youth with SED could be endorsed before the new millennium.

The National Advisory Mental Health Council By Jeanne C. Fox, RN, PhD, FAAN

The National Advisory Mental Health Council By Jeanne C. Fox, RN, PhD, FAAN

Case-mix funding and legislated psychiatric care

The importance of adequately providing acute care hospital services for psychiatric patients can be argued on both humanitarian and cost-effective grounds. In the recent past, however, the humanitarian argument has proved insufficient to insure that the mentally ill receive adequate care. For example, although the humanitarian intentions of those who originally heralded deinstitutionalization are not contested, more recent evidence describing the grim plight of the mentally ill in communities seems to have had little impact on service improvements and, in most communities, services for the mentally ill remain underfunded. According to Gralnick, “deinstitutionalization results in relative neglect of the acutely ill and the consequent amassing of the chronically ill” (Gralnick, 1985). Considering a cost-effective argument, the burden of mental illness on the population is known to be large, making mental illness a major public health problem. In established market economies, for example, 19% of all disabilityadjusted life years are lost to neuropsychiatric disease and intentional injuries. Mental disorders are tied with cancers as the leading causes of disabilityadjusted years of life lost. Worldwide, 10.5% of all disability-adjusted years of life lost are attributable to serious mental disorders and intentional injuries, more than any other health problem (The World Bank, 1993). Community epidemiological surveys conducted in the United States and Canada reveal that approximately 22% of the adult population are affected by a mental disorder during any given year (National Advisory Mental Health Council, 1993; Bland, Newman, and Orn, 1988), and that between 2% and 3% of the adult popula-

Health care reform for Americans with severe mental illnesses: report of the National Advisory Mental Health Council.

This report was produced in response to a request by the Senate Committee on Appropriations that the National Advisory Mental Health Council prepare and submit a report on the cost of insurance coverage of medical treatment for severe mental illness commensurate with the coverage of other illnesses and an assessment of the efficacy of treatment of severe mental disorders. About 5 million Americans (2.8% of the adult population) experience severe mental disorders in a 1-year period. Treating these disorders now costs the nation an estimated $20 billion a year (with an additional $7 billion a year in nursing home costs). These costs represent 4% of total U.S. direct health care costs. When the social costs are also included, severe mental disorders exact an annual financial toll of $74 billion. This total accounts for the dollar costs of shortened lives and lost productivity, as well as the costs incurred in the criminal justice and social service systems. However, it cannot begin to account in human terms for the enormous emotional cost and pain borne by Americans with severe mental illness and by their families. Many myths and misunderstandings contribute to the stigmatization of persons with mental illness and to their often limited access to needed services. For example, millions of Americans and many policy makers are unaware that the efficacy of an extensive array of treatments for specific mental disorders has been systematically tested in controlled clinical trials; these studies demonstrate that mental disorders can now be diagnosed and treated as precisely and effectively as are other disorders in medicine. The existence of effective treatments is only relevant to those who can obtain them. Far too many Americans with severe mental illness and their families find that appropriate treatment is inaccessible because they lack any insurance coverage or the coverage they have for mental illness is inequitable and inadequate. For example, private health insurance coverage for mental disorders is often limited to 30-60 inpatient days per year, compared with 120 days or unlimited days for physical illnesses. Similarly, the Medicare program requires 50% copayment for outpatient care of mental disorders, compared with 20% copayment for other medical outpatient treatment. These inequities in both the public and private sectors can and should be overcome.(ABSTRACT TRUNCATED AT 400 WORDS)

The report of the National Advisory Mental Health Council

The report of the National Advisory Mental Health Council

The Battered Chairman Syndrome

John Romano, born in Milwaukee, Wis, in 1908, graduated from Marquette University's Medical School in 1934, and trained in psychiatry, neurology, and psychoanalysis at Yale University, University of Colorado, and Harvard University. In 1942, he became professor and chairman of the Department of Psychiatry at the University of Cincinnati College of Medicine, working with colleagues such as Milton Rosenbaum and George Engel and others destined to influence postwar American psychiatry and medicine. In 1946, he became chairman at the University of Rochester (NY), where for the last 23 years he has been the Distinguished University Professor of Psychiatry (continuing in active emeritus status since 1979). His department was a magnet for many of today's leading investigators and scholars in psychosomatics, schizophrenia, and epidemiology. He was a member of the original National Advisory Mental Health Council of the National Institute of Mental Health in 1946, and his national advisory role since,