12-21-07
AOTA Comments on NIMH Draft Strategic Plan
December 21, 2007
National Institute of Mental Health
8280 Greensboro Drive, Suite 300
McLean, Virginia 22102
Re: The National Institute of Mental Health Draft Strategic Plan
Dear Director Insel,
The American Occupational Therapy Association (AOTA) represents over 37,000 occupational therapists, occupational therapy assistants and students of occupational therapy. We appreciate the opportunity to comment on the draft of the National Institute of Mental Health’s (NIMH) Strategic Plan released on November 20, 2007. AOTA submits these comments regarding the draft and looks forward to providing additional comments on the Institute’s future research and training priorities.
Occupational therapy is a profession dedicated to the maximization of function and performance for the purpose of helping people lead satisfying, productive lives through preventative and restorative interventions. AOTA supports NIMH’s strategic plan, particularly its emphasis on outcomes and providing a research base upon which practitioners can improve interventions and services for people with mental disorders. Occupational therapy can make valuable contributions regarding prevention, treatment, rehabilitation and reintegration of people with mental illness. In order to more effectively use occupational therapy services and research for the benefit of people with mental illness AOTA suggests conducting research that encompasses participation and engagement in activities of meaning in people’s lives. To accomplish this goal AOTA identified some perspectives from which we developed our comments:
- Research on outcomes should extend beyond symptom reduction.
- Outcomes related to social participation and engagement are critical to recovery and reintegration.
- Side-effects and the consequences of treatment interventions must be investigated to improve the safety and quality of interventions and improve treatment adherence.
- Individual and societal repercussions of mental illness, such as obesity and poverty, should be researched from the perspectives of prevention, health promotion, treatment, and reintegration.
- Mental health interventions must have a client-centered approach that honors clients’ desires and priorities. Interventions must also utilize a strength-based perspective that builds upon the existing abilities and resources of the individual.
- The focus of NIMH research should be broadened to include the interaction between the brain, behavior and the environment. As a profession, occupational therapy has a body of knowledge on the interaction between the person and environment in regard to causation, prevention and treatment of illness as well as how it affects functional performance.
- The scope of mental health research should extend from recovery to rehabilitation and reintegration into family, community work and social life.
Research informed by the occupational therapy perspective will demonstrate the efficacy and overall importance of social participation and engagement as a means for addressing the impairments associated with mental illness. Such research can also address valuable resiliency factors that will lead to improved prevention measures supporting NIMH’s goals of strengthening the public health impact of NIMH research.
While AOTA will provide comment on each of the four strategic objectives that constitute the draft plan, we will focus heavily on Strategic Objective 3: Develop New and Better Interventions that Incorporate the Diverse Needs and Circumstances of People with Mental Illness because it relates most directly to the unique contributions that occupational therapy can make to enhance prevention, treatment and recovery for people with mental illness.
Strategic Objective 1: Promote Discovery in the Brain and Behavioral Sciences to Fuel Research on the Causes of Mental Disorders.
Research should focus on how interaction between the brain, behavior and the environment interact to contribute to mental disorders. A critical area of research is how interaction with the environment can be modified to avoid, reduce or ameliorate mental disorders or the symptoms caused by the disorders. The full impact of the interaction between these three areas is critical to understanding the cause of mental disorders but also necessary to identify possible preventative or therapeutic interventions. Because occupational therapy focuses on the interaction between the person and environment in an effort to maximize function, performance and independence, the contributions of our researchers in this area can be valuable to achieving this objective and should be supported.
Strategy 1.1: Develop an integrative understanding of basic brain-behavior processes that provide the foundation for understanding mental disorders.
The study of brain-behavior processes should extend from biological factors (genetic/brain imaging), to behavioral components (executive functioning/affect/ regulation), to daily living functioning (ADL’s/IADLs). This would help complete the picture of mental disorders gained from the research in this area.
Strategy 1.4: Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.
AOTA recommends that this area should also include occupational therapy experts in clinical and behavioral sciences as they would be important to help identify and understand the fundamental behavioral components, including functional dimensions, underlying causes and implications of mental disorders.
Strategic Objective 2: Chart Mental Illness Trajectories to Determine When, Where and How to Intervene.
This strategic objective is vital to targeting appropriate interventions. Occupational therapy has a significant role in changing behavior or modifying environmental interaction to preempt, halt and reverse the progression of mental illness. AOTA supports this objective because it is the experience of many of our members that their services are not available to individuals at the right time. Access to occupational therapy and other interventions as preventative measures or quickly after onset provides enhanced opportunities to address mental disorders before the symptoms and impairments of function progress. Research should be done to validate this.
Strategy 2.1: Define the developmental trajectories of mental disorders.
Occupational therapy practitioners and researchers work with people across the lifespan and many focus heavily on developmental process of both children and adults (including the elderly) in regard to how development affects both the function and performance of daily activities. The perspective of occupational therapy researchers, working collaboratively with neurologists and others, regarding the relationship between behavior, the environment and development would help provide information about how changes and developmental variations in the brain impact function.
Strategy 2.2: Enhance understanding of how cultural diversity may influence the developmental trajectories of mental illness.
The inclusions of this strategy will help address the problem of health disparities based on cultural, ethnic and racial factors. AOTA is committed to supporting efforts to eliminate health disparities and has engaged with Congress and Federal agencies to address our members’ concerns in this area. Research in this area will improve both prevention and treatment. Occupational therapy has been focused on creating culturally sensitive interventions for people with mental disorders and for addressing suicide prevention among various high risk populations such as Native American youth, Hispanic youth, seniors and gay/lesbian/bi-sexual/transgendered youth and adults.
Strategic Objective 3: Develop New and Better Interventions for Mental Disorders that Incorporate the Diverse Needs and Circumstances of People with Mental Illness.
This strategic objective is vigorously supported by AOTA and we thank NIMH for emphasizing the needs addressed by this objective. Occupational therapy has always started with the individual and their unique circumstances and needs so that people can lead full, productive and satisfying lives. Occupational therapy uses strength based interventions focused on the individual to help people remain engaged both in their lives and in their treatment.
The statement about the importance of personal decision-making in medicine is supported by AOTA but the term “medicine” should be changed to “mental health care” in order to reflect the full array of services necessary to address the impact of mental illness on individuals, families and communities.
Strategy 3.1: Further develop innovative interventions and designs for intervention studies.
Promotion of new trials that focus on intervention response and side effects will lead directly to research based evidence that will improve the quality of interventions available to people with mental illness. Emphasis on accelerating and validating research that maximizes the ability of current interventions to reduce symptoms and improve adherence and functioning while minimizing side effects is fully supported by AOTA and clearly marks important research in which occupational therapy should be among NIMH’s primary investigators and collaborators. Occupational therapy interventions for people with mental disorders are often focused on improving treatment adherence, maximizing function and allowing the individual to return to productive and meaningful activities.
Strategy 3.2: Expand and deepen the focus to personalize intervention research.
This section states several important principles that underlie occupational therapy in mental health. Outcome measures should indeed include measures of functioning and adherence to treatment; both of which can be impacted by occupational therapy intervention. Research must also explicitly investigate co-morbid health or functional outcomes or effects associated with interventions, including pharmaceutical interventions. It would be critical to include occupational therapy in developing standardized measures of functional outcome, as occupational therapy already has a broad knowledge base in this area. AOTA is particularly pleased that NIMH is addressing the longer term effects of interventions.
NIMH’s reference to children is applauded but AOTA notes that except for references to schools, this is the only mention of children. NIMH should include, across the strategic plan, attention to the unique and different needs of children.
Strategy 3.3: Strengthen the application of mental health interventions in diverse care settings by examining community and intervention delivery approaches and how they may affect intervention outcomes.
AOTA applauds the inclusion of this strategy as it enables research that views the person within their environment and provides information on the effectiveness of interventions in various settings. The role and presence of occupational therapists in community settings such as long-term care facilities for the elderly and k-12 schools and early intervention provides opportunities for researching interventions with specific populations in their natural environments. Occupational therapy, though present in these settings is often underutilized in addressing mental illness.
AOTA would like to see occupational therapy listed when NIMH discusses different types of mental health providers, specifically when related to settings such as long-term care facilities for the aged and schools.
Strategy 3.4: Identify and systematically study elements of personalized mental health care.
Patient preferences, culturally competent practice and client-centered, strength-based approaches to intervention are critical to treatment adherence and improved outcomes related to both symptom reduction and avoidance or minimization of side effects and co morbidities. Tools developed to detect and monitor illness progression should include measures of community functional performance.
Strategic Objective 4: Strengthen the Public Health Impact of NIMH Supported Research.
Both dissemination of research that can produce improved outcomes as well as a broad health promotion agenda are necessary to achieve this important objective. AOTA supports NIMH in its effort to expand its public health impact and encourages efforts on the part of NIMH to engage in initiatives to reduce the burden of stigma on mental illness. An important way to reduce stigma is to empower individuals with mental disorders to regain function so that they can actively participate in everyday activities with their friends, families, co-workers and communities. Access to supplemental services essential to maintaining recovery and promoting independence such as occupational therapy to address daily living skills and vocational rehabilitation are critical to reducing stigma by making participation and engagement in all aspects of life possible for people with mental disorders.
Stakeholder input regarding the development of services research is vital and fully supported by AOTA. Providing evidence for patients and providers alike regarding interventions that reduce symptoms and improve functional performance is essential to translating research science to evidence-based practice and ultimately improving the system of care for people with mental disorders.
Strategy 4.3: Strengthen partnerships between NIMH and its stakeholder groups (e.g., patients, families, service providers, advocacy groups).
With the recent focus and interest in the provision of mental health services in a wide range of settings, the inclusion of a strategy to strengthen relationships with key stakeholders is vital. Improving the relationship with the Department of Education and getting a better understanding of the range of mental health needs and available resources in schools is particularly supported by AOTA. School-based and early intervention settings are now the largest and fastest growing area of practice for occupational therapy and AOTA sees school-based mental health as a natural expansion of our current roles with children and students.
AOTA commends NIMH on a well crafted and forward looking strategic plan that includes new areas of research which promote people with mental illness living productive and satisfying lives. As partners in meeting the needs of the people with mental illness and disseminating relevant translational research to our members and those they serve, we continue to emphasize research as a priority for our organization so that we can demonstrate the effectiveness of occupational therapy and measure its impact on people’s lives. Thank you for the opportunity to share our thoughts on NIMH’s draft strategic plan and we look forward to working with you as you finalize the plan and continue to provide the research necessary to improve the health and wellness of people with or at risk of mental illness.
Sincerely,
Christina A. Metzler
Chief Public Affairs Officer
