Beverly Pringle

Global research challenges and opportunities for mental health and substance-use disorders

The research agenda for global mental health and substance-use disorders has been largely driven by the exigencies of high health burdens and associated unmet needs in low- and middle-income countries. Implementation research focused on context-driven adaptation and innovation in service delivery has begun to yield promising results that are improving the quality of, and access to, care in low-resource settings. Importantly, these efforts have also resulted in the development and augmentation of local, in-country research capacities. Given the complex interplay between mental health and substance-use disorders, medical conditions, and biological and social vulnerabilities, a revitalized research agenda must encompass both local variation and global commonalities in the impact of adversities, multi-morbidities and their consequences across the life course. We recommend priorities for research — as well as guiding principles for context-driven, intersectoral, integrative approaches — that will advance knowledge and answer the most pressing local and global mental health questions and needs, while also promoting a health equity agenda and extending the quality, reach and impact of scientific enquiry.This article has not been written or reviewed by Nature editors. Nature accepts no responsibility for the accuracy of the information provided.

A Strategic Approach for Prioritizing Research and Action to Prevent Suicide

It is time to strategically apply science and accountability to the public health problem of preventable suicide. U.S. suicide rates have remained stable for decades. More than 36,000 individuals now die by suicide each year. A public health-based approach to quickly and substantially reduce suicides requires strategic deployment of existing evidence-based interventions, rapid development of new interventions, and measures to increase accountability for results. The purpose of this Open Forum is to galvanize researchers to further develop and consolidate knowledge needed to guide these actions. As researchers overcome data limitations and methodological challenges, they enable better prioritization of high-risk subgroups for targeted suicide prevention efforts, identification of effective interventions ready for deployment, estimation of the implementation impact of effective interventions in real-world settings, and assessment of time horizons for taking implementation to scale. This new knowledge will permit decision makers to take strategic action to reduce suicide and stakeholders to hold them accountable for results.

Diagnosis lost: Differences between children who had and who currently have an autism spectrum disorder diagnosis

Autism spectrum disorder diagnoses sometimes change due to misdiagnosis, maturation, or treatment. This study uses a probability-based national survey—the Survey of Pathways to Diagnosis and Services—to compare currently diagnosed (n = 1420) and previously diagnosed (n = 187) children aged 6–17 years based on retrospective parental reports of early concerns about their children’s development, responses to those concerns by doctors and other healthcare providers, the type of provider who made the first autism spectrum disorder diagnosis, and the autism spectrum disorder subtype diagnoses received (if any). Propensity score matching was used to control for differences between the groups on children’s current level of functioning and other current characteristics that may have been related to diagnosis loss. Approximately 13% of the children ever diagnosed with autism spectrum disorder were estimated to have lost the diagnosis, and parents of 74% of them believed it was changed due to new information. Previously diagnosed children were less likely to have parents with early concerns about verbal skills, nonverbal communication, learning, and unusual gestures or movements. They were also less likely to have been referred to and diagnosed by a specialist. Previously diagnosed children were less likely to have ever received a diagnosis of Asperger’s disorder or autistic disorder.

Reported Wandering Behavior among Children with Autism Spectrum Disorder and/or Intellectual Disability

OBJECTIVE To characterize wandering, or elopement, among children with autism spectrum disorder (ASD) and intellectual disability. STUDY DESIGN Questions on wandering in the previous year were asked of parents of children with ASD with and without intellectual disability and children with intellectual disability without ASD as part of the 2011 Survey of Pathways to Diagnosis and Services. The Pathways study sample was drawn from the much larger National Survey of Children with Special Health Care Needs conducted in 2009-2010. RESULTS For children with special healthcare needs diagnosed with either ASD, intellectual disability, or both, wandering or becoming lost during the previous year was reported for more than 1 in 4 children. Wandering was highest among children with ASD with intellectual disability (37.7%) followed by children with ASD without intellectual disability (32.7%), and then children with intellectual disability without ASD (23.7%), though the differences between these groups were not statistically significant. CONCLUSIONS This study affirms that wandering among children with ASD, regardless of intellectual disability status, is relatively common. However, wandering or becoming lost in the past year was also reported for many children with intellectual disability, indicating the need to broaden our understanding of this safety issue to other developmental disabilities.

Toward Enough of the Best for All: Research to Transform the Efficacy, Quality, and Reach of Mental Health Care for Youth

The articles in this special journal issue observe the same paradox about mental health services for children and adolescents expressed in this old joke about food. Taken together, they make the case that current mental health care for children and adolescents is of poor quality and questionable effectiveness, and, moreover, is delivered in inadequate doses to a only a fraction of the nation’s youth who need it. In order to address these shortcomings in quality, quantity, and effectiveness, the authors mainly agree to eschew traditional individual-level approaches to addressing mental health problems in favor of a public health approach. A public health approach would target the population, in contrast to individuals, with a range of consistently high-quality services to meet diverse needs and, thus, provide maximum mental health benefit for the greatest number of youth. A public health approach, and the requisite system alterations recommended in this journal, imply that change must occur at all levels, from Federal and State policies to mental health care agencies, treatment providers, and individual interventions. Foster and McCombs-Thornton (2010), for example, would target the economics of mental health care, given that financing and cost help to determine care quality and intensity by informing and influencing decisions about providing and using mental health services. Horwitz et al. (2010) propose policy levers be used to compel child welfare agencies to deliver evidence-based parent training programs. Stelk and Slaton (2010) assert that States must radically strengthen their mental health infrastructures if they are to support and withstand the process of transformational improvement. Kelleher and Atkins (2010) posit that transition from a clinician-patient model to a public health approach will require changes in organizational culture and capacity, including assimilation of new information technologies and accountability systems. Atkins et al. (2010) cite the emerging consensus to incorporate mental health services into schools as renewed motivation to find best models for integrating academic learning with emotional, mental, and behavioral health. Garland et al. (2010) focus on improving usual care and assert that to do so, providers and agencies need readily available feedback on treatment process, outcomes, and implementation of evidence-based strategies. Schoenwald et al. (2010) recommend rethinking of the child mental health workforce and distribution of labor. Taking aim at clinical practice, Alegria et al. (2010) argue that traditional clinical approaches to child mental health too often fail youth from diverse backgrounds by ignoring culture and context. Heflinger and Hinshaw (2010) exhort providers to The views expressed in this commentary do not necessarily represent the views of the NIMH, NIH, HHS, or the United States Government.

Age of Parental Concern, Diagnosis, and Service Initiation Among Children With Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) require substantial support to address the core symptoms of ASD and co-occurring behavioral/developmental conditions. This study explores the early diagnostic experiences of school-aged children with ASD using survey data from a large probability-based national sample. Multivariate linear regressions were used to examine age when parent reported developmental concern to doctor, received ASD diagnosis, and first obtained services. Children whose parents had concerns about their childs verbal communication reported earlier ages for all outcomes when compared to children of parents who did not have verbal communication concerns. Children whose parents had concerns about their childs nonverbal communication or unusual gestures/movements received an earlier diagnosis than children whose parents did not have these specific concerns.

Estimating the prevalence of any impairing childhood mental disorder in the national health interview survey

This study investigates whether the six‐item Strengths and Difficulties Questionnaire SDQ (five symptoms and one impact item) included in the National Health Interview Survey (NHIS) can be used to construct models that accurately estimate the prevalence of any impairing mental disorder among children 4–17 years old as measured by a shortened Child/Adolescent or Preschool Age Psychiatric Assessment (CAPA or PAPA). A subsample of 217 NHIS respondents completed a follow‐up CAPA or PAPA interview. Logistic regression models were developed to model presence of any child mental disorder with impairment (MDI) or with severe impairment (MDSI). Models containing only the SDQ impact item exhibited highly biased prevalence estimates. The best‐performing model included information from both the five symptom SDQ items and the impact item, where absolute bias was reduced and sensitivity and concordance were increased. This study illustrates the importance of using all available information from the six‐item SDQ to accurately estimate the prevalence of any impairing childhood mental disorder from the NHIS. Copyright

Developing and implementing collaborative research in global mental health: the NIMH Hubs

Abstract Background The US National Institute of Mental Health (NIMH) has stimulated and participated in efforts to identify priorities in global mental health research and facilitate research activities aimed at meeting the greatest challenges. Methods In 2010, we convened clinicians and researchers, service users, representatives from ministries of health, and non-governmental organisations operating in low-income and middle-income countries (LMICs) to discuss what research is needed to reduce the mental health treatment gap. Findings Ensuring that research meets the needs of end-users was a dominant theme. We subsequently developed an initiative, Collaborative Hubs for International Research on Mental Health in Low- and Middle-Income Countries (CHIRMH), with the goal of establishing regional hubs that would conduct public-health-relevant research through strategic collaborations and develop research capacity. Applicants needed to show collaboration with local or regional government agencies and non-governmental organisations that ensured access to service provider and service user viewpoints. The initiative required teams to conduct research on task-sharing for the delivery of mental health interventions, thus addressing the dearth of mental health human resources—one contributor to the treatment gap. Interpretation NIMH currently has four funded Hubs in south Asia, sub-Saharan Africa, and Latin America. Each Hub coordinates a collaborative team of investigators and stakeholders from at least five countries and multiple institutions in a given region. CHIRMH teams have launched studies applying mixed methods to test models of mental health service delivery in various health system environments in LMICs, established research training opportunities, and enriched the mental health research networks in LMICs. Funding NIMH.

Data for Building a National Suicide Prevention Strategy What We Have and What We Need

Suicide is a leading cause of death in the U.S. As both the rate and number of suicides continue to climb, the country struggles with how to reverse this alarming trend. Using population-based data from publically available sources including the Web-based Injury Statistics Query and Reporting System, National Survey on Drug Use and Health, the authors identified patterns of suicide that can be used to steer a public health-based suicide prevention strategy. That most suicide deaths occur upon the first attempt, for example, suggests that a greater investment in primary prevention is needed. The fact that definable subgroups receiving care through identifiable service systems, such as individuals in specialty substance use treatment, exhibit greater concentrations of suicide risk than the general public suggests that integrating suicide prevention strategies into those service system platforms is an efficient way to deliver care to those with heightened need. The data sets that reveal these patterns have both strengths (e.g., population-level) and weaknesses (e.g., lack of longitudinal data linking changing health status, intervention encounters, suicidal behavior, and death records). Some of the data needed for crafting a comprehensive, public health-based approach for dramatically reducing suicide are currently available or may be available in the near term. Other resources will have to be built, perhaps by enhancing existing federal surveillance systems or constructing new ones. The article concludes with suggestions for immediate and longer-term actions that can strengthen public data resources in the service of reducing suicide in the U.S.

Connecting Science and Practice in Child and Adolescent Mental Health Services Research

Collaboration between researchers and stakeholder groups is a potentially powerful mechanism for strengthening the quality of mental health research and for amplifying its public health impact. For stakeholders, collaboration offers opportunities to help shape research questions; participate in data collection and interpretation; and improve local capacity to access and use research findings. For researchers, collaboration can build understanding of what stakeholders want and need from research; enhance capacity to frame research questions and findings in language and metrics of value to stakeholders; and provide opportunities to contribute science-backed knowledge to decision-making processes in real world settings. Key stakeholder groups can include the recipients and providers of care, public and private care systems, health plans, schools, family service and faith-based organizations, correctional systems, and employers providing mental health benefits. This commentary reflects on the path that NIMH has taken in fostering researcher-stakeholder collaboration, particularly regarding child and adolescent mental health research. It describes the goals that NIMH set out to achieve, steps taken to realize those goals, lessons learned from those efforts, and possible next steps.