Commentary: Devising Prevention and Treatment Strategies for the Nation's Diverse Populations With Mental Illness

The mission of the National Institute of Mental Health (NIMH) is to reduce the public health burden of mental and behavioral disorders through research. As the Surgeon General reported in 1999, the public health burden of mental illness is not shared equally—mostly because of disparities in access to services and variations in the quality of care. Recent epidemiological studies have documented many of these disparities, demonstrating that mental disorders, unlike other medical illnesses, remain largely outside of the nation's health care system. Clearly, the success of NIMH depends on identifying where the public health burden is greatest and on devising prevention and treatment strategies that will be most effective for those populations.

The NIMH recently convened a meeting of experts to consider how best to improve research directly relevant to better serving Latinos with persistent mental disorders. A summary of this meeting, published in this issue, highlights key areas of research that will help inform future research efforts in this important area ( 1 ).

How can research have the greatest impact on those with the greatest need? First, we need to document the needs. Epidemiological studies, including studies in Latino populations, have tracked not only the prevalence of psychiatric disorders but also the use of services in various facets of our society. More recently, NIMH funded a large, regionally diverse, six-site collaborative study to examine the effects of ethnicity on clinical diagnosis and treatment assignment among African-American, Latino, and Caucasian patients with mood disorders. In addition to epidemiological studies, a critical part of the NIMH strategy includes large-scale, practical treatment trials in real-world health care settings to study treatment of such disorders as schizophrenia, depression, and bipolar disorder. Studies such as the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for schizophrenia and Alzheimer's disease, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) for treatment-resistant depression, and the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) represent the first and largest studies of their kind.

In order for clinical research to provide results that address the needs of the American public, the research needs to include diverse populations. Recently, NIMH issued a new policy to monitor the recruitment of participants in NIMH-sponsored clinical research studies that expect to enroll 150 or more human participants. The purpose of this policy is to ensure the establishment of realistic recruitment targets from the outset of a project and achievement of these targets throughout the course of the research—particularly the recruitment and retention of underrepresented racial and ethnic minority participants.

The results of recent clinical research demonstrate that current treatments, although helpful for many, are not sufficient for all patients with serious mental illness. Research is essential to develop new treatments and to identify which people will benefit most from the various treatments available. Research can also inform policy, including ways to optimize the dissemination and implementation of scientifically based treatments. The severe fragmentation of our present treatment system, as noted in the report from the President's New Freedom Commission on Mental Health, is an urgent national problem. Finding ways to restructure this system may open the door for creating a more equitable and responsive network for individuals who have unique linguistic needs or who come from cultural backgrounds with a very different understanding of mental illnesses or their management.

In short, NIMH research must offer pragmatic solutions to improve access to mental health care and to find effective interventions that can be implemented in diverse settings and populations within our nation.