A. I’ve just completed 25 years at the National Institute of Mental Health [NIMH], where I’ve had the opportunity to both initiate and support the development of several areas of research, research training, and even NIMH’s latest clinical training grants. Thus, my professional life has been identified with NIMH through half of its 50 years of existence. It has been an exciting period of remarkable growth for psychiatric research, during which we’ve witnessed revolutionary changes in clinical treatment options, mental health services organization, and financing. Some of these changes have been influenced by the NIMH and others by broader changes in our profession and in the U.S. health care system.

Before coming to NIMH, I completed my psychiatry residency at the Massachusetts General Hospital [MGH]. At that time, Leon Eisenberg, chairman, had attracted Gerald Klerman to join him to head clinical and community psychiatry and Seymour Kety to head the basic-science research programs. My initial interest was in community psychiatry, particularly at the neighborhood health center level of interaction with primary health care. Specifically, the Bunker Hill Health Center was the clinical location for a third- and fourth-year research fellowship that was sponsored by Alexander Leighton at the Harvard School of Public Health, along with Jonathan Borus and Gerald Klerman at the MGH. Epidemiological research methods were identified by these advisors as essential to understanding both the treatment need (prevalence of disorders) in communities and the effectiveness of treatment services. I mention the names of these mentors, because each influenced and helped to shape my research career.

Prior to residency, I completed a one-year medical internship at Montefiore Hospital in the Bronx, N.Y., which has strong programs in social and community medicine. As a medical student at Indiana University, I was involved in developing a neighborhood health center in an underserved area. For many medical students in that era, it was a time of great impatience with government programs that were being promised for the underserved by Lyndon Johnson’s "Great Society."

A. When I came to NIMH in 1975 as a commissioned officer in the Public Health Service, then NIMH Director Bert Brown and Morton Kramer, director of the Division of Biometry and Epidemiology, requested that I join Irving Goldberg in developing a research program focused on mental health services provided in primary health care settings. This area of research had been developed in England by Mort’s good friend, Michael Shepherd, who helped us start the NIMH program.

It has been gratifying to see the remarkable development of this research area by such colleagues as Wayne Katon and Ken Wells, who have tested and improved U.S. models of depression treatment in primary care settings. These are now being applied in developing countries and considered for broader application by the World Health Organization (WHO).

The primary care research program led to several research contracts and an analysis of U.S. mental health services, titled the "DeFacto U.S. Mental Health Services System," for President Carter’s Commission on Mental Health. Based on the deficiencies in available epidemiological information and service-use data documented by the commission, support was provided for the Epidemiologic Catchment Area [ECA] study. I was able to organize and lead this study after being appointed by Herb Pardes to succeed A. Kramer as division director in 1978. The ECA has been one of the most productive collaborative research programs in the NIH with over 500 research publications from the NIMH, five participating sites, and numerous graduate students who are able to access the public-use data tapes. The combination of both epidemiology and a new services research and health economics emphasis proved to be a synergistic and productive arrangement.

Developing the Diagnostic Interview Schedule (DIS) for the ECA led to a collaborative effort between Lee Robins of Washington University, St. Louis, and Robert Spitzer, who was then directing the creation of DSM-III. This activity initiated a 20-year investment in the development of diagnostic criteria, first with APA and later as the U.S. government coordinator for linking the WHO International Classification of Diseases 10th revision process, under Norman Sartorius, with the DSM-III-R and DSM-IV revisions. Part of that process involved supporting the WHO development of epidemiological (CIDI), clinical (SCAN), and personality disorder (IPDE) diagnostic instruments, which incorporate DSM-IV and ICD-10 criteria.

After I had been director of the Division of Biometry and Epidemiology for seven years, NIMH Director Shervert Frasier asked me to lead the Division of Clinical Research. There we initiated national plans for research on schizophrenia and childhood disorders and the first public mental health education program, the Depression Awareness Recognition and Treatment (D/ART) program. Other highlights included the initiation of a multisite genetics study in schizophrenia, bipolar disorder, and Alzheimer’s disease and the recently released Cooperative Agreement on Treatment of Attention Deficit Disorder led by Peter Jensen. Another child mental health–related activity included the first multisite methodological, epidemiological study of child and adolescent disorders (MECA), which tested the Diagnostic Interview Schedule for Children (DISC) and provided prevalence and service use data used in the recent Surgeon General’s report on mental health.

During my seven years of directing the Division of Clinical Research, there was a marked expansion of major Clinical Research Centers (with the support of NIMH Director Louis Judd), completion of the Treatment of Depression Collaborative Research Project, and continued support for the Collaborative Depression Project, which still provides essential data on the long-term clinical course of major depression.

With the return of NIMH to NIH in 1992, there was another reorganization of NIMH under Frederick Goodwin, which included my new Division of Epidemiology and Services Research. A major objective of this new alignment was to position NIMH to contribute its research efforts to President Clinton’s Task Force on Health Care Reform, as well as to other emerging health policy concerns such as the cost of health insurance parity for mental disorders. With the arrival of Steve Hyman as NIMH director in 1997, I was able to focus more fully on the application of 20 years of research to some of the most significant health policy issues of managed behavioral health care, parity insurance coverage, and the global burden of disease posed by mental disorders in U.S. and international settings.

A. The psychiatric research community has two major priorities: to support the best clinical applications of current scientific evidence and to overcome obstacles that limit our ability to prevent mental disorders or to reduce the disability and impairment that remain even after the best application of current treatments.

Some of the clinical applications include the development of needed improvements in mental health systems of care so that incentives for competition in the area of quality, outcomes, and cost-effectiveness can replace the current strong incentives to simply provide care at the lowest cost. Developing more effective psychopharmacological agents and replicable psychotherapy/psychosocial interventions will make such outcome assessments that much more feasible and cost-effective.

On the basic science side, we are privileged to live in a time when neuroscience, genetics, and behavioral science are some of the most exciting frontier areas in all of science. Our concern must be that major mental disorders such as schizophrenia, mood, anxiety, and addictive disorders receive the level of attention that are suggested by their inordinate contributions to the global burden of disease.

A. Increased attention to the area of medical ethics in health research is critical for the continued credibility of our research enterprise to patients, their families, and the broader society. There is no debate about the need to protect the rights of human subjects, only a discussion about the most credible approaches to accomplishing that goal. Institutional Review Boards, which are competent, objective, free of conflicts of interest, and well trained in ethical issues in medical research are essential for our ability to continue to improve treatment for our patients. Steve Hyman and David Shore at NIMH have identified such training as a high priority for all NIH-supported research.

The potential abuse of medicine for either scientific or political purposes is an area where I have had a long-standing interest. In 1989 I served as the scientific director of an NIMH-supported State Department visit to assess the former Soviet Union’s abuse of psychiatry to justify the incarceration of political dissidents. Since that very sobering experience, I’ve been able to contribute to some of the new initiatives in Russian mental health services through the U.S./Russian Commission on Science and Technology’s Health Committee. However, the need to guard against the use of psychiatry for purely social-control purposes continues to be an issue in this country and around the world.