Mental Health Disparities Research at the National Institute of Mental Health (NIMH): Cross-Cutting Aspects of the NIMH Strategic Plan for Research

Sponsored by Office for Research on Disparities and Global Mental Health (ORDGMH), NIMH

On August 26, 2015, the NIMH Office for Research on Disparities and Global Mental Health (ORDGMH) conducted the first of three webinars. With more than 120 participants, this webinar  disseminated scientific findings from three exemplary NIMH-funded researchers that represent the four Strategic Objectives of the revised NIMH Strategic Plan for Research, emphasizing the need to reduce and eliminate mental health disparities.

The meeting began with a presentation by Stacy Drury, Ph.D. on molecular links to mental health and health disparities.  The study focused on the impact of early life stress on the developing brain at both molecular and circuit levels across the life course among racially diverse groups. The researchers explored the ability of the early caregiver-child relationship to buffer the negative impact of early life stressors at the molecular, physiological, and behavioral levels.

The research team is using novel genomic technology to look at mental illnesses and identify genomic markers that will allow them to track the trajectory of at-risk children. They are also investigating how adverse early experiences result in altered behavioral, psychological, cognitive, and physical health outcomes. Their model proposes that alterations in developing stress response systems in turn change developmental trajectories and alter neural circuitry. The underlying changes in neural circuits lead to altered behavioral and psychological health outcomes. Health disparities may be reduced if caregiving in early life can buffer the harmful impact of adverse experiences.

Understanding deviations from normal human development at the earliest possible points can have a great impact on long-term health and wellness. The ability to alter negative trajectories therefore lies in prevention so that the long-term consequences associated with early adversity are reduced. A large part of this protection can come from the quality of the early caregiving environment according to preliminary results of this research.

The second presentation, by Patricia Areán, Ph.D., addressed opportunities for large-scale recruitment of underserved populations. Although randomized clinical trials (RCTs) are the gold standard for the evaluation of treatment impact on a population, samples are rarely diverse and the trials are expensive and lengthy. Studies that include low-income and ethnically diverse populations often have a high attrition rate. To address this barrier, this study used smart phone and iPad technology to test the feasibility of a fully remote RCT using an online research portal.

Americans use smart devices at a high rate, including ethnic minority populations. People with limited incomes tend to prefer smart devices over desktop computers because they are portable and provide many functions in one device. It has been shown that minorities use mobile health apps more than Whites, and that the number of mental health apps has been increasing.

Recruitment for this study (using Craigslist and similar methods) was extremely successful; the goal of 150 participants was reached in one week. The researchers screened 3,000 people in six months and ultimately enrolled 1,100 participants, as the study received an extension. The team was able to replicate the ethnic diversity of the United States almost identically, with the exception of the Hispanic population. The 12-week study randomized participants with depressed mood into use of one of three treatment apps that targeted cognitive function and depression. The apps collected data on social connection based on number of texts, and collected data on the number of places people went using GPS technology. The apps also provided therapeutic games and sent daily reminders to participants to engage in healthy activities.

The researchers found no differences between groups in app use or engagement, although Alaska Natives were more likely to drop out of treatment in all three groups for reasons that could not be determined. The study concludes that it is feasible to conduct a fully remote study, and that the use of smart devices in research is appealing to most minority populations, based on the study’s rapid and high recruitment numbers and low drop-out rate.

In the final presentation, Lauren Brookman-Frazee, Ph.D. addressed the importance of studying disparities related to children with autism spectrum disorder (ASD) in the context of community-based research. Publicly funded community- and school-based mental health programs play an important role in the treatment of school-age children with co-occurring behavioral and psychiatric conditions associated with ASD ‒ up to 70 percent of these children meet the criteria for a co-occurring psychiatric condition. Services are typically provided in outpatient community clinics or in schools, and are general in nature; they do not specialize in addressing ASD or the needs of racial and ethnic populations. Available evidence has documented disparities in the identification of ASD: children from minority backgrounds with ASD are less likely to be linked to services, and, for children who are successfully linked to care, there are documented disparities in the quality of services.  There have also been concerns about gaps between the quality of treatment delivered in evidence-based practices (EBPs) in research settings and the treatment delivered in routine care.

Dr. Brookman-Frazee’s research team is developing strategies for implementing successful practices that can be adopted, implemented, and sustained. Their work includes efforts to understand the impact of training providers on treatment disparities, as this type of training has the potential to reduce disparities in other areas, such as access and quality of care. Specifically, Dr. Brookman-Frazee’s research team developed the intervention, An Individualized Mental Health Intervention for Children with Autism Spectrum Disorder (AIM HI).  AIM HI is a package of parent-mediated and child-focused behavioral EBPs to reduce challenging behaviors in children with ASD from ages 5-13 served in mental health settings. The intervention was designed specifically for providers who do not specialize in ASD. AIM HI trains therapists to deliver strategies directly to children to help them learn new skills and teaches parents how to support their children’s learning. Early data suggests that it is viable to train providers to deliver AIM HI. Both parents and therapists have seen a reduction in challenging behaviors among children receiving the intervention.  The study results have broad application concerning disparities research and mental health services. It is promising that the researchers found a lack of disparity in many of the key treatment processes found in the context of EBP implementation.