1 Update From the NIMH Joshua A. Gordon, M.D., Ph.D. Director, NIMHJuly 1, 2017
2 Welcome About the NIMH Director Director’s Research PrioritiesCurrent State of NIMH Science Highlights and Updates Participation in Research Future Directions Note: this slide needs to be updated when final
3 Introduction About the NIMH Director Director’s Research PrioritiesCurrent State of NIMH Science Highlights and Updates Participation in Research Future Directions Note: this slide needs to be updated when final
4 Background University of California, San Francisco Columbia UniversityReceived dual M.D./Ph.D. Pioneered methods to study brain plasticity in mice Columbia University Psychiatry residency, neuroscience fellowship Joined Department of Psychiatry Director of the Columbia University/New York State Psychiatric Institute Adult Psychiatry Residency Program Research focus on neural activity in mice carrying mutations of relevance to psychiatric disease Maintained psychiatric practice, caring for patients who suffer from the illnesses studied in the lab
5 Director Priorities About the NIMH DirectorDirector’s Research Priorities Balanced Portfolio: Timeframes Short-term: Suicide Prevention Medium-term: Circuit Neuroscience Long-term: Computational & Theoretical Current State of NIMH Science Highlights and Updates Participation in Research Future Directions Note: this slide needs to be updated when final
6 NIMH Portfolio BalanceGood Science Strong Study Design High Standard of Rigor Potential Impact Diversity Subject Matter Workforce Research Participants Timeframes My number one priority is to support excellent science - funding decisions are based on proposed study design, adherence to the highest standards of rigor, and potential impact on the field. Excellent science requires diversity in subject matter, workforce, research participants, and timeframes. Such diversity is the cornerstone of a strong and balanced research portfolio.
7 Research Priorities Medium-term Goals: Neural CircuitsShort-term Goals: Suicide Prevention Identify implementable evidence-based practices and knowledge gaps Medium-term Goals: Neural Circuits Develop technologies to interrogate neural circuits, and ultimately improve the understanding and treatment of mental health disorders Long-term Goals: Computational Psychiatry Develop computational perspectives and approaches to improve the understanding and treatment of mental health disorders It is important to invest in research across diverse timeframes; research that has the potential to yield results or improve clinical care over the short, medium, and long-term. I came in with scientific priorities, and am beginning to explore how to accomplish them.
8 NIMH Updates About the NIMH Director Director’s Research PrioritiesCurrent State of NIMH Budget Grants Interactions with SAMHSA Science Highlights and Updates Participation in Research Future Directions Note: this slides needs to be updated when final
9 NIMH Budget Updates On May 5, 2017, President Trump signed the Consolidated Appropriations Act of 2017 providing funds through September 30, 2017. NIMH received $1.602 billion, a 3.5 percent increase over the FY 2016 appropriation. President’s budget proposal, released on March 16, is proposing major cuts to the NIH. We don’t know yet how this will affect NIMH. We will know more about FY 18 in the coming months.
10 NIMH Budget Updates Josh used his own words here (uptick in 2016, # projects holding steady, etc.) FY NIMH awarded an estimated 587 new and competing research project grants (RPGs) in 2016, and achieved an overall success rate of approximately 23 percent (defined as number of RPG applications funded divided by the number of applications received. NIMH awarded grants to 84 New Investigators, and achieved a success rate of approximately 24 percent for Early Stage Investigators. FY NIMH anticipates awarding more than 600 new and competing research project grants (RPGs) in FY 2017, with an estimated success rate of 23 percent, as can be seen in Figure 1 below. FY 2017 will be the first year NIMH will exceed 600 competing RPGs.
11 NIMH Budget Updates This figure shows the number of applications received and the number of awards made through the 25th percentile “that come out of the review boards "for RPGs. Not included are applications/awards higher than the 25th percentile. Note that in Figure 2, the total number of funded grants does not add up to 587, as not all grants are percentiled. Note: NIH/Office of Extramural Research (NIH/OER) has a new method for showing success rates – we will be using this in the future.
12 21st Century Cures Act: Interactions Between NIH and SAMHSAKey Provisions for Mental Health Care: Appoints Directors of NIMH, NIDA, NIAAA to SAMHSA advisory councils Encourages collaboration to ensure evidence-based practices Strengthens existing mental and behavioral health care parity legislation Includes broad provisions to assist for special populations Increases inter-Departmental collaboration and consultation between federal agencies. SAMHSA will receive guidance from NIMH, NIDA, and NIAAA concerning the scientific evidence-base of prevention, treatment, and recovery programs. Continued support of SAMHSA’s mental health block grants – The bill generally requires states to use at least 10% of their mental health block grants on early intervention for psychosis.
13 Update on RAISE: Implementation Science to Broad Clinical CareClient Medication/ Primary Care Psychotherapy Family Education and Support Supported Employment and Education Case Management In 2008, the NIMH launched the Recovery After an Initial Schizophrenia Episode (RAISE) project. RAISE is a large-scale research initiative that began with two studies examining different aspects of coordinated specialty care (CSC) treatments for people who were experiencing first episode psychosis. One study focused on whether or not the treatment worked better than care typically available in community settings. The other project studied the best way for clinics to start using the treatment program. Slide provided by Bob Heinssen on 3/6/17.
14 NIMH RAISE Findings Influenced States’ Adoption of Evidence-Based Care for First Episode PsychosisDates and Milestones July, 2009 RAISE studies begin December, 2013 RAISE feasibility study completed January, 2014 H.R ($25M set-aside for FEP) April, 2014 NIMH/SAMHSA provide guidance to states December, 2014 H.R. 88 ($25M set-aside for FEP) October, 2015 RAISE clinical trial completed CMS coverage of FEP intervention services December, 2015 H.R ($50M set-aside for FEP) RAISE = Recovery After and Initial Schizophrenia Episode. States’ status is based on: November 2014 review of states’ revised FY14 CMHBG program plans submitted in response to the 5% set-aside for FEP treatment programs. 2015 updates to state plans from GA, ME, and MN about new FEP initiatives related to the set-aside initiative. Plans submitted to SAMHSA in 2015 for the FY2016-FY2017 set-aside initiative. Plans downloaded from https://bgas.samhsa.gov/ Mental Health Block Grant Plans: https://bgas.samhsa.gov/
15 Projected Coordinated Specialty CarePrograms in 2018 $100M in FY16 – FY17: 187 community clinics 2008 2014 2016 2018 RAISE findings influenced States’ adoption of evidence-based care programs for first episode psychosis. New Federal funding has accelerated implementation of those programs. The number of operational CSC programs increased 15-fold over the 10 year period of Slide provided by Bob Heinssen on 3/6/17.
16 Science Updates About the NIMH Director Director’s Research PrioritiesCurrent State of NIMH Science Highlights and Updates Circuit Basis of Psychosis Suicide Prevention Race and Ethnicity in the Mental Health Research Network Brief Therapy for Hispanic Youth with Anxiety and Depression Participation in Research Future Directions Note: this slide needs to be updated when final
17 Science Highlight: Circuit Basis of Psychosis?Turning to recent exciting advances from NIMH-funded research, NIMH funds a lot of great research. I like to talk about some highlights that I found interesting and hopefully you will as well…. Copy variants and overall risk for schizophrenia
18 Understanding Genetic PredispositionDisease Phenotype Mutation Slide adapted from Josh's talk called "Form gene to behavior in a mouse model of schizophrenia predisposition" for the Federation of European Neuroscience Societies (FENS) Brain Conference, September 2016. Gene Cell Circuit System Behavior
19 The 22q11 Deletion Syndrome (22q11DS)De novo copy number variant High penetrance (25-30%) for psychosis 0.5-2% of schizophrenia cases 22q11.2 22q11 De5-2% of Schz. Most Schz is idiopathic. Although this accts for small portion of schz, it is important Chun…Zakharenko, Nature Medicine, 2017
20 22q11DS Model Mice Chun…Zakharenko, Nature Medicine, 2017
21 22q11DS Mice have Deficits in Thalamocortical Synaptic StrengthIt is known that this can be reversed by haloperidol – this study demonstrates that it can also be reversed with MicroRNS 338 (inhibit D2 receptors) Chun…Zakharenko, Nature Medicine, 2017
22 MicroRNA 338 Overexpression Rescues DeficitsChun…Zakharenko, Nature Medicine, 2017
23 Understanding Genetic PredispositionDisease Phenotype Mutation Dgcr8 miRNA DRD2 Psychosis? One of a handful of papers linking genes with behavior with steps along the way that suggest mediators. Chun…Zakharenko, Nature Medicine, 2017
24 Science Highlight: Suicide ScreeningAmerican Journal of Preventive Medicine
25 Science Highlight: Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) 2017
26 New Findings from ED-SAFEThree phase study of 1,400 suicidal patients in eight U.S. EDs Treatment as usual (phase 1) Universal suicide risk screening (phase 2) Universal suicide risk screening + intervention (phase 3): Secondary suicide risk screening by ED physician Discharge resources Post-ED telephone calls to reducing suicide risk Miller…ED-SAFE Investigators, JAMA Psychiatry, 2017
27 Universal Suicide Screening is Possible to ImplementBoudreaux…Miller, Am J Prev Med, 2016
28 Universal Suicide Screening Increases DetectionIt is estimat.ed that an additional 3M at-risk individuals could be identified nationwide with ED screening alone. Boudreaux…Miller, Am J Prev Med, 2016
29 Universal Screening Plus Intervention Reduces Number of Suicide AttemptsIntervention led to a 30% decrease in suicide attempts over the 52-weeks follow-up, as compared to standard emergency treatment care Miller…ED-SAFE Investigators, JAMA Psychiatry, 2017
30 Science Highlight: Tracking Disparities in Access to Care2016
31 Mental Health Research Network (MHRN)MHRN is the nation’s preeminent source of population-based research on mental health, partnering with 13 health system research centers that provide care of a diverse population of over 12.5 million people in 15 states (1) The MHRN is … Administrative, clinical, and claims data are translated to a common set of data standards at each site. This data resource dramatically increases the efficiency of ongoing and future research while protecting patient privacy.
32 Racial-Ethnic Differences in Psychiatric Diagnosis and TreatmentAre Racial-Ethnic Differences in Psychiatric Diagnosis and Treatment Present in Health Care Systems Across the US? (n= 7.5 million adults) Racial-ethnic differences in the diagnosis and treatment of psychiatric conditions persist, especially for Blacks Blacks were nearly twice as likely as Whites to receive a diagnosis of Schizophrenia Depression and anxiety diagnoses were lower among racial-ethic minorities compared to non-Hispanic Whites Exception: Native American and Alaskan Native groups had similar rates as Whites This study looked at data from 7.5 million adults at 11 health care systems to answer the question “Are Racial-Ethnic Differences in Psychiatric Diagnosis and Treatment Present in Health Care Systems Across the US?” They found that … Karen Coleman, Greg Simon et al, 2016, Psychiatric Services Coleman…Simon, Psychiatric Services, 2016
33 Science Highlight: Brief Therapy for Pediatric Anxiety and Depression 2017
34 Clinical Trial of Children and Adolescents with Depression or AnxietyEnrolled 185 children and adolescents (ages 8 – 16) with depression or an anxiety disorder Random assignment to assisted referral care (ARC) or brief behavioral therapy (BBT) BBT addressed both depression and anxiety using a streamlined approach Children and adolescents in the BBT group showed greater improvement than those in the ARC group Weersing…Iyengar, JAMA Psychiatry, 2017
35 Striking Benefits for Hispanic Children and AdolescentsHispanic youth who received BBT showed the greatest improvement and performed best on measures of functioning . Weersing…Iyengar, JAMA Psychiatry, 2017
36 Active Participation in ResearchAbout the NIMH Director Director’s Research Priorities Current State of NIMH Science Highlights Participation in Research Big Data Approaches All of Us Cohort Future Directions Note: this slide needs to be updated when final
37 Big Data Approach to Identifying Depression SubtypesEmphasis big datasets, high tech
38 Patterns of Resting State ConnectivityDrysdale…Liston, Nature Medicine, 2017
39 Clustering Patients Based on Connectivity*Imaging and clinical data – patients and controls This is one possible clustering mechanism Drysdale…Liston, Nature Medicine, 2017
40 Subtypes Differ in Clinical DimensionsDrysdale…Liston, Nature Medicine, 2017
41 Subtypes Differ in Responsivity to Prefrontal Cortex Repetitive Transcranial Magnetic StimulationModel constructed on other patients and then applied here (Bayesian methods) Drysdale…Liston, Nature Medicine, 2017
42 NIH All of Us Research ProgramHistoric effort to gather data from one million or more people in the U.S. Focus on individual differences in lifestyle, environment, and biology Paving the way toward precision medicine Big data approaches will pave the way toward precision medicine Large sample sizes are required, highlighting the importance of broad, active participation in research
43 Moving Forward About the NIMH Director Director’s Research PrioritiesCurrent State of NIMH Science Highlights Participation in Research Future Directions Note: this slide needs to be updated when final
44 The Road Ahead Prioritize excellent science, and within the realm of excellent science, diversity. Focus on learning and working closely with all of you to gain insight that can help inform the future directions of our research programs. Address challenges facing NIMH. Think more broadly about neuroscience, psychiatry, and public health. Help build momentum towards treatments that can change the lives of individuals, families, and communities affected by mental disorders. These are my priorities: excellent science, and within the realm of excellent science, diversity. This position at NIMH gives me an exciting opportunity to think more broadly about neuroscience, psychiatry, and public health; and to help build momentum towards treatments that can change the lives of individuals, families, and communities affected by mental disorders.
45 NIMH’s Mission Research = Hope Thank you.