Thomas R. Insel M.D.
National Institute of Mental Health
National Institutes of Health
Department of Health and Human Services
Fiscal Year 2008 Budget Request - Substance Abuse and Mental Health Research and Services
Committee on Appropriations
Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
U.S. House of Representatives
Thursday March 1, 2007
Mr. Chairman, and members of the Committee, I am pleased to be here on behalf of the National Institute of Mental Health (NIMH) to tell you about our progress in understanding and treating mental illnesses, and about our active collaborations with our fellow research Institutes, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and with the Substance Abuse and Mental Health Services Administration (SAMHSA). The FY 2008 budget includes $1,405,421,000. In my statement, I will call to your attention our Nation’s immense burden of mental and behavioral disorders, provide a brief review of our research activities and accomplishments, and describe some of our ongoing collaborations with NIDA, NIAAA, and SAMHSA.
BURDEN OF MENTAL ILLNESS
The NIMH mission is to reduce the burden of mental and behavioral disorders, such as depression, schizophrenia, autism, and bipolar disorder, through research on mind, brain, and behavior. Every year, more than 44 million Americans experience significant mental illness symptoms that interfere with everyday living.- According to the World Health Organization, mental disorders are the leading cause of medical disability in the United States for people ages 15-44.
Research over the past decade has transformed our understanding of mental disorders by two fundamental insights. First, we now understand mental disorders as brain disorders. Each of these illnesses can be studied as a disorder of specific brain circuits, and treatments can be developed that are specific to these circuits. Second, in contrast to most traditional neurologic disorders such as Parkinson’s or Alzheimer’s disease, mental disorders begin early in life. Indeed, we now realize that mental disorders along with addictive disorders are the most common chronic illnesses of young people in this nation. Hence, a high level of lifetime disability results from these illnesses. To reduce this tremendous disability, the Institute adopted the NIH clinical research vision of focusing on the four P’s: Predicting who is at risk for developing disease; Pre-empting the disease process; Personalizing interventions; and ensuring that clinical research involves Participation from the diversity of people and settings involved in health care.
One application of the four P’s can be seen in NIMH’s practical clinical trials, which collectively are helping us to personalize treatments for people with schizophrenia, depression, and bipolar disorder. DNA collected from participants of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) practical clinical trial led to the discovery of genetic variations associated with response to antidepressants. Through the inclusion of a diverse group of people, this research also found that the genetic variation that predicted a favorable response was less commonly found in African-Americans. This pharmacogenomic approach may someday transform the treatment of mental disorders, allowing clinicians to optimize therapy based on a patient’s personal biology.
NIMH practical trials have also addressed participation by enrolling participants with multiple disorders, who may represent a significant portion of the target treatment population but are usually excluded from clinical research. These trials, which included 10,000 patients across 200 sites, involved primary care practices as well as more traditional research settings. As a result, the findings from practical trials may be more readily useful for a broad spectrum of Americans outside of academic health centers. . The results describe not only changes in symptoms, but also changes in functioning and whether a treatment improves quality of life, caregiving burden, or a person’s use of health services.
But NIMH’s most ambitious initiatives are moving beyond current treatments to find ways to predict who will develop a disorder and design strategies that will pre-empt the first psychotic break or the disability of PTSD. While the Institute has long focused on prevention, for the first time, with the power of genomics and imaging, we can target individual patterns of risk to predict who will benefit most from a pre-emptive intervention. In FY 2008, NIMH plans to launch several initiatives focused on early detection and pre-emption of psychosis in schizophrenia.
The large-scale practical trials supported by the Institute taught us that too many people do not respond to our best evidence-based treatments. We need a new generation of more effective treatments for each of the mental disorders. While available antidepressants appear effective for depression most of the time, their effects are delayed by several weeks and are usually incomplete. Last year we pledged to develop medications with different mechanisms of action that would relieve depression in hours rather than weeks. I am pleased to tell you that this year NIMH scientists reported two such medications with significant antidepressant effects within six hours. The positive effects were long-lasting; after a single treatment, patients showed significant improvement for up to a week in some cases. While the widespread clinical use of both of these medications is limited by side-effects and delivery methods, these discoveries are important for re-setting the bar for what we expect with antidepressants and for re-focusing research on novel molecular targets for new medication development.
New targets have also been the focus for developing new treatments for other mental disorders beyond depression. The past year saw the first agents for the cognitive deficits in schizophrenia, the development of the first medication to enhance behavioral treatments of anxiety disorders, and the first FDA approved compound for autism. In FY2008, NIMH plans to expand its efforts in treatment development, with an enhanced focus on medications that reverse the cognitive deficits in schizophrenia, additional studies of novel antidepressants, and new efforts in autism, anxiety disorders, and eating disorders.
SCIENCE TO SERVICE
For many mental disorders, effective, research-informed treatments exist, but they may be difficult to obtain or find within the community. To address this issue, NIMH partners with other Institutes and organizations, including NIDA, NIAAA, SAMHSA, state governments, and advocacy groups, to work toward rapid and effective distribution and implementation of science-based information about mental disorders, substance abuse, and co-morbidity.
One key research goal for NIMH is to study the impact and ways to enhance the implementation of effective mental health treatments in real-world health care practices. Examples of such practices include multi-systemic therapy (MST), a treatment model for serious antisocial behaviors in youth. Through numerous studies funded by NIMH, NIDA, and NIAAA, MST has been shown to reduce recidivism rates in chronic juvenile offenders and at significant cost savings. Another example is multidimensional treatment for foster care (MTFC), which seeks to improve behavior among youth in foster care through therapy, training, and support for the children or adolescents and their caregivers. Rigorous testing has shown MTFC to be effective in reducing delinquency and other deleterious outcomes. Current studies are exploring the best methods for implementing these treatments in different, real-world health care delivery systems to provide sound guidance to health care systems and needed treatment to all those who may benefit from it.
NIMH also is collaborating with SAMHSA’s Center for Mental Health Services (CMHS) on the Mental Health Transformation State Incentive Grant program, to develop a next generation of mental health services implementation studies to transform the often fragmented arenas of mental health services, treatments, and supports into a seamless and responsive mental health care delivery system. NIMH’s support will contribute to cross-site evaluations and possible research projects to augment the progress enabled by the CMHS Transformation grants. NIMH is also co-sponsoring with CMHS a research funding opportunity to study the effectiveness of interventions delivered through two of the Center’s services initiatives (“Safe Schools, Healthy Students,” and “Systems of Care”); the nature and impact of routine prevention or clinical practice; and factors related to successful implementation of preventive or treatment interventions. These efforts are action steps highlighted in NIMH’s National Advisory Council’s recent “Road Ahead” report, which developed recommendations to maximize the benefit of research on public mental health.
Finally, I want the Committee to know that I have never been so hopeful about breakthroughs for mental disorders. At NIMH, we feel the urgency for delivering better services and for closing the gap between what we know and what we do in the community. As I have said in previous years, we must create a highway from science to service. But this year, you should know that we are on the cusp of creating a new science for mental disorders. The power of genomics and imaging, which have transformed other areas of medicine, are now being applied to schizophrenia, depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD), and autism. I have every reason to believe that in FY2008 research will enhance our understanding of each of these disorders, introducing an era of biomarkers and new treatments that will ultimately reduce the public health burden of these illnesses.
Thomas R. Insel, M.D.
Director, National Institute of Mental Health
Thomas R. Insel, M.D., is Director of the National Institute of Mental Health (NIMH), the component of the National Institutes of Health charged with generating the knowledge needed to understand, treat, and prevent mental disorders. Prior to his appointment as Director in 2002, Dr. Insel was Professor of Psychiatry at Emory University. There, he was founding director of the Center for Behavioral Neuroscience, one of the largest science and technology centers funded by the National Science Foundation and, concurrently, director of an NIH-funded Center for Autism Research. From 1994 to 1999, he was Director of the Yerkes Regional Primate Research Center in Atlanta. In addition to these administrative posts, Dr. Insel had a distinguished research career. He was a pioneer in the field of social neuroscience, with classic studies of the neurobiological basis of complex social behaviors in animals. Prior to moving to Emory, Dr. Insel was a scientist in the NIMH intramural program from 1979 to 1994. Early in this period, he conducted clinical research on obsessive-compulsive disorder, completing some of the first treatment trials for OCD using the selective serotonin reuptake inhibitors (SSRI) class of medications. He has published over 200 scientific articles and four books, including The Neurobiology of Parental Care (with Michael Numan) in 2003.
Dr. Insel has served on numerous academic, scientific, and professional committees, including 10 editorial boards. He is a member of the Institute of Medicine, a fellow of the American College of Neuropsychopharmacology, and is a recipient of several awards (A. E. Bennett Award from the Society for Biological Psychiatry, Curt Richter Prize from the International Society of Psychoneuroendocrinology, Outstanding Service Award from the U.S. Public Health Service, and a Distinguished Investigator Award from NARSAD). Dr. Insel graduated from the combined B.A.-M.D. program at Boston University in 1974. He did his internship at Berkshire Medical Center, Pittsfield, Massachusetts, and his residency at the Langley Porter Neuropsychiatric Institute at the University of California, San Francisco.
Department of Health and Human Services
Office of Budget
Richard J. Turman
Mr. Turman is the Deputy Assistant Secretary for Budget, HHS. He joined federal service as a Presidential Management Intern in 1987 at the Office of Management and Budget, where he worked as a Budget Examiner and later as a Branch Chief. He has worked as a Legislative Assistant in the Senate, as the Director of Federal Relations for an association of research universities, and as the Associate Director for Budget of the National Institutes of Health. He received a Bachelor’s Degree from the University of California, Santa Cruz, and a Masters in Public Policy from the University of California, Berkeley.
Kessler, RC, Chiu, WT, Demler, O, Merikangas, KR, Walters, EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005 Jun: 62, 617-627.
 “Prevalence of serious emotional disturbance in children and adolescents.” Mental Health, United States, 1996. Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 1996.
Last revised: April 19, 2011