Addressing the Mental Health Crisis through

Research

Shelli Avenevoli, Ph.D.

Deputy Director, NIMH

NIH Advisory Committee to the Director

June 8, 2023
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

2
 NIMH Vision and Mission

VISION
NIMH envisions a world in which mental illnesses are
prevented and cured.

MISSION
To transform the understanding and treatment of mental illnesses through
basic and clinical research, paving the way for prevention, recovery, and cure.

3
Burden of Mental Illness: U.S. Disability-Adjusted
Life Years (DALYs)
Cumulative U.S. DALYs for the Leading Disease/Disorder Categories by Age (2019)
Data Courtesy of IHME, GHDx

4
 Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

5
COVID-19 Impacts on Mental Health:
Increased Rates of Symptoms

Symptom prevalence in adults

%Adults with symptoms during past 7 days

6
 Symptom Change across Pandemic

TRAJECTORY OF SYMPTOMS IN PANDEMIC

Prior research on trauma

exposure:
• Initial symptoms improve
for most
• Significant minority may
have long-term or chronic
mental illness
• Social inequities increase
trauma exposure and
mental health vulnerability
and care

7 Twenge et al., Journal of Anxiety Disorders, 2021

 Risks for Poor Outcomes

Nature and severity of exposure Pandemic-specific factors (youth)

• Exposed directly to death or injuries • Living in areas with severe outbreaks
• Trauma type • Losing a family member
Individual differences • Having caregiver who is a frontline
• History of trauma or mental illness worker
• Ongoing stressors, including • Being worried about COVID-19
occupational and financial strain • Disruptions in routines
• Substance use/abuse
• Experiencing more adverse childhood
• Female experiences
• Non-white
• Experiencing financial instability,
Environment food shortages or housing availability
• Few social supports HHS, 2021

8
Disparities in Mental Health Outcomes and
Factors Associated with those Outcomes

9 Xiao et al., JAMA Psychiatry, 2022

 Increased Risk of SARS-CoV-2 Infection and
Death Among Those With Mental Disorders
Risk of Infection Risk of Death

Fond et al., JAMA Psychiatry, 2021

10
 Impact of Policy Changes on Mental Health

Access to Free Groceries/Meals Improved Mental Health

Among Food Insufficient Individuals

11 Adapted from Nagata et al., American Journal of Prevention Medicine, 2021

 Disruptions in Care

• Among >650k Medicare beneficiaries with Schizophrenia or

Bipolar 1 disorders during the acute phase of the pandemic
 20% outpatient visits
 20% antipsychotic and mood stabilizer prescription fills
 28% emergency department visits and hospital admissions
Utilization rebounded yet was lower than 2019
• 30% of adolescent mental health service users were unable
to receive care during the pandemic

12 Image source: Medicare.gov

Shifts in Behavioral Health Treatment

• Telehealth use rate increased from

2.2% in January 2020 to 65.2% in April
2020, and remained stable at 65.6% in
June 2020 (Yu et al 2021)
• From January 2020 to January 2021,
telehealth availability increased by
77% for mental health and 143% for
substance use disorder (Cantor et al 2021)
• Significantly lower telehealth usage by
Blacks, Hispanics, and Asians than
non-Hispanic Whites (Yu and Bekerian, 2023)

13
 NIMH Response to COVID-19

NIMH-Sponsored Initiatives
• Urgent Award: COVID-19 Mental Health Research (PAR-22-112, PAR-22-113)
• COVID-19 Pandemic Mental Health Research (NOT-MH-22-100)
• Social, Behavioral, and Economic Impact of COVID-19 in Underserved and Vulnerable
Populations (NOT-MH-21-330)
• COVID-19 Related School Disruptions Impact on Mental Health, Cognitive, Social, and
Emotional Development of Children (NOT-MH-21-225)

NIMH Participation
• Social, Behavioral, and Economic Research on COVID-19 Consortium (PAR-21-213)
• Research to Address Vaccine Hesitancy, Uptake, and Implementation among Populations
that Experience Health Disparities (NOT-MD-21-008)
• Simulation Modeling and Systems Science to Address Health Disparities (NOT-MD-20-025)

14
 3 Year COVID-19 and Mental Health Summary

P R E V I O U S R ES EA R C H I S R E L E VA N T
• Initial widespread distress is not sustained but even small
sustained new and worsened illness cannot be absorbed by the
healthcare system

B I D I R E C T I O N A L R E L AT I O N S H I P E X I S T S

• Mental illness leaves you vulnerable to infection and death

• COVID-19 (particularly severe infection) is associated with incident
mental illness

PA N D E M I C E X P L O I T S S Y S T E M I C & S O C I A L I N E Q U I T I E S
• Many health disparity populations (e.g., racial and ethnic minorities, less
privileged SES, rural residents) experience compounded impacts

RESEARCH NEEDS PERSIST

Outstanding questions include (but are not limited to):
• Why are people with mental illness more susceptible to infection and poor outcomes?
• How does infection change long term psychosis risk?
• How to extend mental health workforce?
• What are most impactful SDOH to target?

15
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

16
Surgeon General’s Advisory on Youth Mental Health

17 HHS, 2021
 Mental Disorders are Highly Prevalent

Lifetime Prevalence of Any Major Depressive Episode in the Past

Mental Disorder: Aged 12 Year: Aged 12 to 17; 2021
to 17; 2001-2004

18 Merikangas et al., 2010 SAMHSA, National Survey on Drug Use and Health, 2021
 Rates of Depression are Increasing Among Youth

Major Depressive Episode (MDE) and MDE with Severe Impairment in

the Past Year Among Youths Aged 12 to 17: 2004-2020

19 SAMHSA, National Survey on Drug Use and Health, 2021

 Rates of Suicide are Increasing Among Youth

Crude Suicide Rates Among Youth in the United States (2001-2021)

Data Courtesy of CDC

20
 Increases in Youth Suicide Rates Differ by
Race/Ethnicity (Ages 10-24)
Crude Suicide Rates in the United States (2018-2021)
Data Courtesy of CDC

21
 Emerging Risk Groups: Black Youth and Pre-Teens

Crude Suicide Rates Among Black Youth (Aged 15-19)

(2001-2020)
Data courtesy of CDC

Crude Suicide Rates Among Children (Aged 5-9)

(1999-2020)
Data Courtesy of CDC

22
Proportion of Youth Receiving Mental Health Care

Percent of children, ages 3 through 17, with a mental/behavioral

condition who receive treatment or counseling

blank Received Did not receive Total %

treatment or treatment or
counseling counseling
% 51.6 48.4 100.0
C.I. 49.6 - 53.5 46.5 - 50.4 Blank

Sample Count 7,144 5,812 blank

Pop. Est. 4,522,442 4,245,505 blank

Data Source: National Survey of Children’s Health, Health Resources and Services Administration, Maternal and
23
Child Health Bureau. https://mchb.hrsa.gov/data/national-surveys
 Disparities in Service Delivery

Received Mental Health Services in the Past Year Among Adolescents,

by Race/Ethnicity: 2015-2019, Annual Averages

Specialty Setting Non-specialty Facility

24 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2015-2019
Factors that can shape the mental health of young people

25 HHS, 2021
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

26
 White House and Congressional Interest in
Mental Health

NIMH submitted a
Professional Judgment
Budget on Serious Mental
Illness to Congress
Winter 2023
NIH engaged with the White
House and provided
Spring 2022 research priorities President released the
Summer 2022 White House Report on Mental
White House identified
Health Research Priorities
mental health as a priority
and Fiscal Year 2024 Budget
March 01, 2022
FACT SHEET: President Biden to
Announce Strategy to Address Our
National Mental Health Crisis, As Part
of Unity Agenda in his First State of
the Union

27
 White House Report on Mental Health Research
Priorities
• Outlines administration-wide needs and
opportunities to advance mental health research
• Areas of emphasis include
 Addressing mental health inequities
 Leveraging digital mental health interventions
 Supporting the mental health workforce
 Increasing the availability, quality, and impact of interventions
 Integrating substance use and mental health research and
treatment
 Developing and improving treatments for serious mental
illnesses
 Preventing fatal and non-fatal suicide outcomes
 Supporting youth mental health

• Highlights several NIMH-supported initiatives

https://www.whitehouse.gov/wp-content/uploads/2023/02/White-House-Report-on-Mental-Health-Research-
28
Priorities.pdf
 President’s FY24 Budget Request for NIMH

• On March 9, 2023, the Administration released the President’s

FY24 Budget Request
 The budget proposes $48.6 billion for NIH, an increase of $920 million
above FY23 enacted levels
 It proposes $2.5 billion for NIMH, an increase of $200 million above
FY23 enacted levels, including
o $130 million to support better diagnostics, improved treatments, and enhanced
precision of mental health care
o $20 million to study the mental health impacts of social media
o $50 million for the Precision Psychiatry Initiative

29
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

 Advancing Learning Health Care to Improve Mental Health
Outcomes
 Transforming the System of Care for Youth Mental Health
 Leveraging Precision Medicine to Transform Therapeutics
 Diversifying Genetics for Next-Generation Treatments

30
 Advancing Learning Health Care to Improve
Mental Health Outcomes
• Clinical effectiveness often declines as
evidence-based interventions move from
controlled research environments to real-
world treatment settings
• Learning health care is a promising data-
driven framework for mitigating this “voltage
drop” and promoting continuously
improving health care
• Learning health systems utilize standard
measures, data science, quality
improvement studies, and real-time
feedback to support immediate
improvements in health care delivery and
patient outcomes
31 AHRQ: About Learning Health Systems, 2019, https://www.ahrq.gov/learning-health-systems/about.html
 Early Psychosis Intervention Network (EPINET):
Growing Efforts to Investigate Early Psychosis

https://www.cmhnetwork.org/news/nimh-launches-the-early-psychosis-intervention-network-
32
epinet-a-national-learning-health-care-system/
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

 Advancing Learning Health Care

 Transforming the System of Care for Youth Mental Health

 Leveraging Precision Medicine to Transform Therapeutics

 Diversifying Genetics for Next-Generation Treatments

33
 Effects of Technology and Digital Media on
Mental Health
• Adolescents who spent more time on new media (including
social media and electronic devices such as smartphones) were
more likely to report mental health issues

34 Adapted from Twenge et al., Clinical Psychological Science, 2018

 Opportunities in Technology and Digital Media

• Bidirectional Influences Between Adolescent Social

Media Use and Mental Health (RFA-MH-23-115/-116)
• Using Just-in-Time Adaptive Interventions to Optimize
Established Adolescent Mental Health Treatments
(RFA-MH-23-170)

https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-23-115.html
35 https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-23-116.html
https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-23-170.html
 NIMH Strategic Framework for Addressing
Youth Mental Health Disparities
• Outlines NIMH’s plans and priorities for
guiding research to address and reduce
mental health disparities among
underserved and underrepresented
youth by 2031
• Three Components:
 Addressing Knowledge Gaps and Expanding
Research Opportunities
 Extending and Supporting Stakeholder
Engagement
 Growing the Youth Mental Health Disparities
Research Workforce
Developed with support from The National Institute on Minority Health and Health
Disparities; The Eunice Kennedy Shriver National Institute of Child Health and Human
Development; and Other entities across NIH, HHS, and the federal government
36
Youth Suicide Prevention Activities and Initiatives

Black Youth Suicide Preteen Suicide

• Initiatives on risk, detection, • Four-part roundtable series: Risk,
prevention, interventions for Black Resilience, & Trajectories in
and Vulnerable Youth Preteen
• Responding to the Alarm: • Suicide (January-June 2021)
Addressing Black Youth Suicide • Assessment of Suicide Thoughts
(webinar on April 21, 2020) and Behaviors among Children
and Preteens (NOT-MH-22-086)

37
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

 Advancing Learning Health Care

 Transforming the System of Care for Youth Mental Health

 Leveraging Precision Medicine to Transform Therapeutics

 Diversifying Genetics for Next-Generation Treatments

38
 Advancing Precision Psychiatry Research

• Biomarker Development Research

 Explore approaches to deliver highly sensitive and specific
biomarkers to guide treatment decisions for major
depression

• Precision Diagnostics Research

 Follow large, diverse cohorts over time using novel
behavioral and physiological methods to better predict
patient prognosis and optimize treatment

39
 Adapting the “Innovation Funnel” Approach to
Treatment Selection for Depression
• Goal: Develop accurate, fast, easy-to-use, and accessible tools to predict
response among multiple existing treatments for depression
• Long-Term Deliverables: Validated clinical tools to accelerate symptom relief
and functional quality-of-life improvement

https://www.nimh.nih.gov/funding/grant-writing-and-application-process/concept-
40
clearances/2022/developing-tools-to-inform-treatment-selection-in-depression
Individually Measured Phenotypes to Advance
Computational Translation in Mental Health (IMPACT-MH)

Goal: Use data-centric and data-driven approaches to

generate more specific and less biased clinical phenotypes
to enrich precision-medicine approaches for diagnostics,
prognosis, and treatment decisions
• Develop a data “infostructure” that
integrates multimodal datasets with an
emphasis on representative, diverse,
and generalizable samples
• Identify relationships within data using
artificial intelligence/machine learning
methods (e.g. Bayesian models)
• Develop robust clinical non-biased
decision-making tools

41 Figure Source: New WHO Handbook: How to Build Digital Health Information Infostructure, www.ictworks.org
Individually Measured Phenotypes to Advance
Computational Translation in Mental Health (IMPACT-MH)

• RFA-MH-23-105/106 (U01/U24)
 Identify/develop behavioral tasks optimized for measuring
individual differences
 Collect data from novel clinical cohorts/identify existing
datasets
 Define novel clinical signatures
 Partner with a Data Coordinating Center

• Application due date: June 14, 2023

https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-23-105.html
42
https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-23-106.html
 Welcome and Agenda

• Impact of the COVID-19 Pandemic on Mental Health

• The Youth Mental Health Crisis

• Meeting the Moment in Mental Health

 Advancing Learning Health Care

 Transforming the System of Care for Youth Mental Health

 Leveraging Precision Medicine to Transform Therapeutics

 Diversifying Genetics for Next-Generation Treatments

43
 Genetic Risk for Schizophrenia is Accounted for
by the Combined Influence of Many Risk Genes

44 Trubetskoy et al., Nature, 2022. Images and more information available online at
https://pubmed.ncbi.nlm.nih.gov/35396580/
 Genes to Biology

Phase 1: High-throughput assays of mutations in a common set of genes (100-250) and pilot
projects to optimize cellular/circuit screens
Data Resource and Administrative Coordination

• Scalable assays to identify key proteins/hubs, molecular mechanisms, and pathways

• Develop analytic pipeline to align molecular/intracellular data with appropriate synaptic,
circuit, and/or organismal assays
Full Scale: Full Scale: Pilot: Pilot:
Molecular Cellular Synaptic Circuit
Center (DRACC)
Data Portal

Phase 2: Extend high-throughput assays and implement medium-throughput, optimized

cellular/circuit/whole organism assays
• Prioritize a set of genes and mechanistic questions to study in appropriate complex cell-
based assays and/or organisms
Full Scale: Mid-Scale:
Synaptic Circuit

Phase 3: Low-throughput comprehensive assays of key pathways/interactors

• Test effect of selected mutations or circuit perturbations (e.g., in mammals) to ask
circuit level questions associated with various behaviors
Mid-Scale:
Comprehensive
Circuit & Behavior
BICCN,
Psych Convergent
BRAIN NCRCRG
ENCODE Neuroscience
Tools
45
 Questions

?
46