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Technical Reviews 20 States enrolled per year, developmental phase this year; field work and assessments next fiscal year. Developmental Technical Assistance 20 States enrolled per year; implementation this fiscal year with field work starting in the fourth quarter.
State Epidemiology Surveys 20 States enrolled per year; phased in this and next fiscal year.
HOMELESS RESEARCH DEMONSTRATION PROGRAM
Question. Dr. Goodwin, why have you proposed eliminating funding for the Substance Abuse Homeless Demonstrations?
Answer. The Homeless Research Demonstration Program for individuals suffering from alcohol and other drug abuse has been proposed for elimination in order to place all of ADAMHA's homeless activities within a new Consolidated Homeless Program. This new $20 million program is intended to generate research-based knowledge to assist States and communities in better meeting the comprehensive needs of homeless individuals, and homeless families with children.
The purpose of the consolidation is to expand the target population by strengthening the program emphasis on the growing subgroup of homeless families with children, as well as the segment of the homeless population with mental disorders co-occurring with alcohol and/or other drug disorders. Each of the new research projects will implement and test the effectiveness of providing a comprehensive mix of mental health, alcohol, and/or other drug abuse services, linked to supportive housing and other support services for homeless individuals and families.
The program will provide up to three years of project support for research grants focused on at least one of four subgroups of the target population: 1) homeless individuals with severe mental illnesses, 2) homeless individuals with alcohol and/or other drug abuse disorders, 3) homeless individuals with mental disorders cooccurring with alcohol and/or other drug disorders, and 4) homeless families with children.
Question. Will the program grantees which were approved in fiscal year 1990 receive their third and final year of funding?
Answer. In FY 1990, NIMH and NIAAA awarded 20 three-year McKinney research demonstration grants. Under this proposal, ADAMHA would not support the 3rd and final year of funding of these grants. Current plans call for these grantees to submit applications for competitive renewals under the new Consolidated Homeless Program. they receive competitive priority scores from a peer review committee, they would then be given priority consideration in subsequent funding decisions. If awarded continuations, these grantees would be able to receive up to three years of additional Federal support.
Question. How much would be necessary to complete the funding commitments to these grantees in fiscal year 1992?
Answer. Continuation costs of these grants are estimated to be $22,000,000 at the fully approved level.
Question. What is the purpose of transferring funding for homeless demonstrations within ADAMHA agencies (from the National Institute on Alcoholism and Alcohol Abuse to the National Institute on Mental Health)?
Answer. Given the focus on the co-morbid homeless population, it makes sense to consolidate ADAMHA's efforts in this area. This is not a transfer of funding, but rather, an entirely new concept in support of the Administration's homeless policy. A process is being developed that will allow for a coordinated program of policyrelevant research to assist program planners and providers in better understanding "what works, for whom, under what conditions, and at what costs" in order to help prevent and abate homelessness among homeless individuals and families with children. Projects supported by the Consolidated Homeless Program would be required to specify an explicit intervention to be tested, a study population relevant to the initiative, and a research design that permits valid and generalizable conclusions to be drawn about the effectiveness of the intervention.
POST TRAUMATIC STRESS DISORDER
Question. Dr. Leshner, several pieces of legislation have been introduced recently which would provide mental health services for post traumatic stress disorder by military personnel returning from the Persian Gulf conflict. What do we know about this disorder and has the National Institute on Mental Health supported research in this area?
Answer. Post Traumatic Stress Disorder (PTSD) develops after the experience of a psychologically distressing event. PTSD affects a large proportion of battlefield veterans for a long period of time after they return home. PTSD veterans suffer from significant impairment, in that they may be aggressive, alienated and withdrawn; suffer from recurrent thoughts and dreams of the war; evidence sensitivity to noise; experience sleep, concentration and memory difficulties; and show a lack of interest in previously enjoyable activities. NIMH is funding research on a variety of PTSD-related issues.
Among these is a study of alteration in cognitive function, including intrusive recollections of the trauma, attempts at avoidance, amnesia, reduced ability to concentrate and hyperalertness. Another focus is depression suffered by a large percentage of persons with PTSD. The distress of these veterans is not limited to PTSD symptoms; a wide range of additional symptoms-physical, psychiatric, familial, interpersonal, and vocational--have similarly been found to accompany exposure to combat. In recent years we have come to recognize that psychological casualties are part of what we must expect from war. This recognition is beneficial in that it permits understanding that these responses to battle are normal, removes stigma, and improves chances for recovery.
Several studies are now underway to aid in the prevention and treatment of PTSD in war veterans. One study compares veterans with combat-related PTSD and well-adjusted combat veterans and psychiatric patients diagnosed with major depressive disorder. Researchers are looking for changes in the way information is processed. Preliminary data indicates that the PTSD patients demonstrate problems with their ability to process information. Findings from this study will improve our understanding of the way in which exposure to trauma impairs the veteran's ability to function in everyday life, and may serve to suggest ways in which treatment can be tailored to the needs of those suffering from the aftereffects of war.
A recent NIMH reorganization has merged research programs studying victims of a range of traumatic events. Findings from studies of victims of interpersonal violence are applicable to our understanding of treatment of the effects of exposure to war. One study is comparing three different behavioral treatments for victims suffering from rape-related PTSD and other psychiatric problems. Results of this important study may help advance the treatment of anxiety, depression and PTSD in persons who experience a range of traumatic events.
The Persian Gulf War has elicited numerous calls to NIMH from both researchers and service providers interested in studying and or assisting a variety of potentially at risk populations, including combat psychiatric casualties, prisoners of war, victims of terrorism, children exposed to extensive media coverage, and families with a loved one serving in the war.
ADVANCES IN TECHNOLOGICAL APPLICATIONS
Question. Dr. Leshner, we have been hearing a great deal recently about increasingly rapid advances being made in technological applications to health and medical research, particularly in the area of neuroimaging. Would you please describe for the Subcommittee the implications of this important technology and the Institute's associated research activity?
Answer. The intricate workings of the brain have remained unknown because of its complexity and its inaccessibility within the skull. As recently as ten years ago, scientists were unable to view the living, functioning human brain. Today, they have at their disposal a number of neuroimaging techniques that make it possible to study brain activity in living, thinking, behaving subjects.
One of the powerful imaging techniques is PET--positron emission tomography. Using PET, neuroscientists can examine subjects in various behavioral states--lying still, reading a book, working math problems, listening to music, moving a finger, etc.--and determine which parts of the brain are involved in these tasks. PET is being used to chart brain activity that occurs only during childhood, which may be tied to the learning and recuperative powers of the young brain. PET is also enabling researchers to compare brain activity in healthy and ill subjects, looking for the biochemical signatures that may characterize specific diseases. PET also allows scientists to determine how drugs affect chemical processes within the brain.
In FY 1990, the NIMH Intramural Program (IRP) used PET techniques to show that: (1) Patients with panic disorder have increased activity in the right hippocampus. (2) Hyperactive adults with childhood onset of the disorder have reduced activity in the parts of the brain related to motor function. (3) Treatment of obsessivecompulsive patients with clomipramine seems to reduce the higher than normal brain activity observed. (4) Adults with severe developmental dyslexia appear to have lower blood flow in the perisylvian portions of the brain.
SPECT--Single Photon Emission Computed Tomography--is a method for reconstructing cross-sectional images of radiotracer distributions. It is less expensive than PET and provides functional information useful for the diagnosis and management of dementias and organic brain disorders. SPECT can be an accurate diagnostic tool for patients with suspected Alzheimer's disease.
MRI--magnetic resonance imaging--is a new tool in which a computer creates images of body structures from magnetic frequencies. MRI images from autistic children have shown that one small region of the cerebellum, a part of the brain near the base of the skull, is usually smaller than in normal children. The abnormality seems to result from abnormal brain development. The region affected is known to control many of the behaviors affected by autism. These findings suggest further studies that may define the critical point in brain maturation when some agent, such as a toxin, virus, or injury, could disturb growth of the affected region.
In FY 1990, the IRP used MRI to continue examination of identical twins where one twin was diagnosed with schizophrenia. The latest results found measurable differences in the size of the twins' hippocampuses. This size difference discriminated the affected from the unaffected twin in 14 out of 15 pairs.
BEAM--or brain electrical activity mapping--provides an advanced form of the familiar EEG brain wave measurements. Recently, BEAM provided convincing evidence that dyslexia is associated with consistently aberrant electrical activity in two well-defined regions of the cerebral cortex. This finding firmly establishes dyslexia as a physical and not a psychological disorder. In addition, the consistent nature of the electrical abnormality may soon provide a means of identifying dyslexic children at a young age and providing them with programs designed to prevent later school failure.
During the next decade, researchers will use these technologies to find structural and biochemical defects associated with mental illnesses. These efforts are designed to lead to routine diagnostic tests that will aid physicians in treating behavioral disorders in the same way that an orthopaedist uses an x-ray to diagnose and treat fractures. Knowing the biochemical abnormality associated with a disease will point researchers towards the aberrant genes involved and help others design better drug therapies.
NIMH is mounting a major initiative to stimulate the use of advanced brain imaging techniques in the study of mental disorders. The centerpiece of this effort will be the establishment of a series of national brain imaging centers dedicated to the study of mental illness. A program announcement has been released requesting applications for Centers for Functional Brain Imaging in Mental
Disorders with the purpose of establishing core resource centers dedicated to multidisciplinary research using PET in the study of the etiology, assessment, pathophysiology, and/or treatment outcome of mental disorders. To manage these and other activities, the Institute has recently created a Neuroimaging and Applied Neuroscience Research Branch.
DECADE OF THE BRAIN
Question. Dr. Leshner, would you please give us an update on the most recent developments in the implementation of the Decade of the Brain?
Answer. NIMH is continuing to implement the Decade of the Brain strategic plan, Approaching the 21st Century: Opportunities for NIMH Neuroscience Research. Advances in brain science have provided new insights in understanding and treatment of mental disorders. NIMH's expanded research and leadership efforts are encouraging scientists and informing the public of the opportunities for progress.
Neuroscience Research Initiatives, Mechanisms, and Programs. National Program in Molecular Genetics of Mental Disorders has several goals. The first is to find the genes responsible for producing vulnerability to major mental disorders such as schizophrenia, manic-depressive disorder, and Alzheimer's disease. Diagnostic Centers for Psychiatric Linkage are gathering clinical and pedigree information and blood samples from families with severe mental disorders. This initiative also includes a National Pedigree Research Service to provide technical assistance and financial support to scientists for the study of large families with many ill members. Coordination of the diagnosis of patients and their family members will allow creation of a National Cell Repository/Gene Bank providing a research resource of cell lines and genetic material.
NIMH has mounted a major initiative, the Brain Imaging Center Program, to expand the use of advanced physical brain imaging techniques in the study of mental disorders. The centerpiece of this effort will be the establishment of a series of national functional brain imaging centers dedicated to the study of mental illness.
A new program of research in cognitive and behavioral neurosciences will be significantly expanded in 1991. The systematic study of normal cognitive processes and disturbances are vital for understanding mental disorders characterized by hallucinations, delusion, misperceptions, thought disorders, obsessions and compulsions. Information processing studies, neuropsychology, and brain imaging also contribute to this research. Based upon a favorable report from the NAS/IOM, NIMH is prepared to initiate activities in 1991 to begin establishment of The Human Brain Project, a centrally located computerized set of databases of all knowledge of the brain in an interactive textual and graphic format.
Development of new therapeutic medications has become a realistic goal with the discovery of specific chemical receptors in the brain, and this holds unprecedented promise for relieving misery and disability. NIMH is playing a major role in ADAMHA-wide medication development initiative. Contracts have been initiated to screen the impact of natural and synthetic chemicals. A chemical synthesis