Q. Which lessons from your work at NIMH are important for your new positions as director of the Office of Research and director of the American Psychiatric Institute for Research and Education?

A. During my time at NIMH, I have been continually impressed by the impact of research findings on improving treatments, demystifying and destigmatizing mental disorders, and giving hope to patients and families whose lives have been affected by these disorders. However, as health care professionals, family members, and other advocates have weighed in on the crucial political battles to make the U.S. health care system more responsive to the needs of patients (particularly in the Carter, Reagan, and Clinton administrations), it has been essential to have an objective research base to which advocates of multiple positions could refer.

My goal at NIMH was to improve the quality and relevance of such debates by providing the most useful clinical, epidemiological, services research, and health economics data independent of advocacy efforts to reform our health care system. As scientific director of three research-based reports from the National Advisory Mental Health Council to the Senate Appropriations Committee over the past eight years, I have seen the benefits of this approach for gaining greater insurance parity between mental and medical/surgical conditions at both the state and federal levels.

The strong support for research provided by the APA Office of Research has been essential for the Association’s ability to provide the Diagnostic and Statistical Manual of Mental Disorders, the classification infrastructure that supports all epidemiological and clinical research in our field. In addition, the emergence of credible services research and research training programs in the Office of Research over the past 16 years has enhanced the research contributions of APA. To be most effective, it will be essential that the new American Psychiatric Institute for Research and Education [APIRE] develop and maintain a reputation for both the objectivity and relevance of its research mission. Hence, the clear designation of this institute as a 501(c)(3) medical research program should help separate it from an advocacy role that will be performed by other components of APA.

Q. What is the distinction between your dual roles as director of both the Office of Research and the American Psychiatric Institute for Research and Education?

A. The Office of Research was created 16 years ago to support all APA research components and to provide a research perspective to the organization. As such, the director assists the medical director, Steve Mirin, with carrying out the mandates of the Association in an efficient manner that is fully informed by the latest research findings. The Office of Research has as a major focus the activities surrounding APA’s Diagnostic and Statistical Manual.

In contrast, the newly created APIRE has been developed to conduct original research supported by grants and contracts obtained from traditional federal programs such as the NIH and SAMHSA [Substance Abuse and Mental Health Services Administration], as well as from foundations and industry. It has the obligation to identify areas of research and research training that cannot be performed equally well in a university setting. The mission statement of the new institute emphasizes a focus on studies and programs of national and international significance, particularly those requiring a national organization to lead efforts involving a broad consortium of academic institutions and practitioners. The Practice Research Network [PRN] is one example of such a consortium that has already contributed substantially to a better understanding of psychiatric practice. For example, the PRN has been valuable in examining patterns and quality of treatment for specific mental disorders, including examining variations in care across different types of health plans and managed care organizations.

Q. How do you see your background in epidemiology interfacing with the current institute emphasis on health services research?

A. I always find it somewhat ironic that there is such a perceived dichotomy between epidemiology and health services research in both the mental health and general health fields. Personally, I sought out training in epidemiology to obtain the necessary research tools for understanding if the policy initiatives to develop community mental health centers and neighborhood Health Centers were actually making a difference in the health status of the communities they serve. Hence, I’ve always sought to combine epidemiological and health services research objectives. Without an understanding of community diagnoses and treatment needs, it is difficult to determine the most appropriate level of outreach effort needed to provide adequate care.

In the past three years, my time has been primarily devoted to addressing health services research and health policy issues such as the access, quality, and cost of mental health services provided under parity-level insurance benefits, particularly in the range of managed and fee-for-service organizations that now characterize our mental health system. However, I’ve continued, with the help of national and international colleagues, to assess the adequacy of existing criteria for defining treatment needs or "medical necessity" (the current parlance of managed care). Since I see epidemiology and nosology as the basic sciences of health services research, my movement back and forth between these areas is somewhat akin to the clinical research investigator moving between his laboratory and the bedside.

Q. Can you tell us of any plans that you have to increase interaction with academic departments of psychiatry?

A. In my first year at APA, I plan to attend meetings of both the chairs and the training directors of departments of psychiatry. Although I will have the benefit of an outstanding Board of Directors and Scientific Advisory Committee from the new institute, I am interested in obtaining a broad perspective on the current status of academic psychiatry. The new institute’s mandate to contribute to improvements in research, research training, and clinical training will require some initial focused efforts within the overall context of issues facing academic health centers.

For those academic centers with the capacity to contribute both to health services research and to improvements in the validity of our diagnostic criteria, there will also be a need to identify priorities for multisite collaborative activities. I expect that the research components of APA will also contribute substantially to defining such priorities.

Q. Do you have specific plans to help foster the development of future psychiatric researchers?

A. The development of future psychiatric researchers has been one objective of the Office of Research since Harold Pincus began this program. He should be credited with building a remarkable support system for young investigators through the young investigators breakfast and poster programs at APA’s annual meeting, the APA mentoring network, APA Web site and manuals listing funding sources, and the growing number of research fellowships supported by industry through APA. Harold has also garnered support for young investigators to participate in secondary data analysis of large survey data sets, including the PRN. In short, the entire field of psychiatry owes a debt of gratitude for his enthusiastic development of the careers of many young investigators.

As someone who helped to develop the PHS epidemiology training program, an M.D./Ph.D. program at NIMH, and multiple research training grants, particularly for minority investigators, I am very appreciative of the synergistic relationship between the NIH-supported programs and APA. However, the ability to combine federal programs with foundation and industry support for research training provides unique opportunities for the new institute. The board of directors for APIRE has already started to address these issues, and I look forward to joining them in this effort.

Q. What other research infrastructure priorities do you have?

A. In reviewing the current capacity of the institute, I believe that the greatest strengths are in the health services research area, particularly with the staff supporting the Practice Research Network. I am delighted that Joyce West will be leading the development of this program, which she helped to start even before finishing her doctorate in mental health services research at Johns Hopkins. There will be a need to enhance our capacity in the area of health economics research to understand the current incentive structures in the large insured and managed care systems, both public and private. Another major area of needed expertise is in the area of quality improvement and quality measurement. Finally, the large data sets that we are accumulating with the Practice Research Network will require additional statistical and computer programming resources.

Q. What funding sources do you envision to carry out the mission of the American Psychiatric Institute for Research and Education?

A. The American Psychiatric Foundation, under the leadership of Abram Hostetter, offers the potential for serving as a substantial source of funding for the institute. I hope that the growth of this foundation will be similar to that witnessed over the past decade for nonfederal research funding sources such as NARSAD [National Alliance for Research on Schizophrenia and Depression]. I will be meeting with the board of the foundation in April to review the priorities and strategic plans that they are developing. In addition, the MacArthur Foundation has a distinguished history of funding substantial parts of the DSM-IV revision process and the Practice Research Network, both of which have been particularly fruitful. There has also been a variety of other foundations and industries, which I hope will be able to continue to expand their funding of research training and research activities. Finally, there has been a growing interest by the NIH institutes, SAMHSA, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Health Care Financing Administration in addressing mental health and substance abuse service and financing issues. As our capacity increases to responsibly address the priorities set by our board and staff, I hope that we will be able to use funding from the above federal agencies to support these efforts.

Q. Is there anything you would like to add?

A. On a final personal note, I would like to express my appreciation to my colleagues at the NIMH as well as to those in the World Health Organization, the World Bank, and the many U.S. and international academic institutions. The professional advances we have been able to make in research and clinical practice over the past 25 years have greatly improved the opportunities of our patients to lead normal and productive lives. While at the American Psychiatric Association, I hope to draw on the enormous talent of APA and these other institutions to focus on the continuing needs of people with mental disorders around the world.

The American Psychiatric Institute for Research and Education could not have been established without the initial steps taken by Mel Sabshin, Robert Trachtenberg, and Harold Pincus. Steve Mirin and Allan Tasman have done an outstanding job of implementing the complex corporate and constitutional supports necessary to realizing the potential of this new organizational arrangement. I look forward to the challenge of adding this new dimension to previous institutional efforts aimed at improving treatment for our patients and the growth of our profession.