RESEARCH ON MENTAL DISORDERS IN RURAL AND FRONTIER POPULATIONS

Release Date:  March 28, 2000

PA NUMBER:  PA-00-082 (see replacement PA-04-061)

National Institute of Mental Health

THIS PA USES “MODULAR GRANT” AND “JUST IN TIME” CONCEPTS.  THIS PA INCLUDES 
DETAILED MODIFICATIONS TO STANDARD APLICATION INSTRUCTIONS THAT MUST BE USED 
WHEN PREPARING AN APPLICATION IN RESPONSE TO THIS PA

PURPOSE

This is a revision of program announcement PA–91-52B, entitled “Research on 
Mental Disorders in Rural Populations,” which was issued in 1991.  The 
National Institute of Mental Health invites grant applications from 
interested investigators for research on populations located in diverse rural 
and frontier areas of the United States.  The purpose of this announcement is 
to stimulate research on mental health problems and risks associated with 
rural and frontier communities and to undertake studies that will: (1) 
improve our understanding of barriers that place limits on the provision of 
care in these areas; and (2) provide information that will improve the 
organization, financing, delivery, quality, effectiveness, and outcomes of 
care for persons with mental disorders living in these diverse communities.

HEALTHY PEOPLE 2010

The Public Health Service (PHS) is committed to achieving the health 
promotion and disease prevention objectives of  “Healthy People 2010,” a PHS-
led national activity for setting priority areas.  This program announcement, 
“Research on Mental Disorders in Rural and Frontier Populations,” is related 
to the priority areas of Mental Health and Mental Disorders.  Potential 
applicants may obtain a copy of "Healthy People 2010" at 
http://www.health.gov/healthypeople/ 

ELIGIBILITY REQUIREMENTS

Applications may be submitted by any domestic public or private nonprofit 
organization and by for-profit organizations, including universities, 
colleges, hospitals, laboratories, units of State or local governments, and 
eligible agencies of the Federal Government.  Racial/ethnic minority 
individuals, women, and persons with disabilities are encouraged to apply as 
Principal Investigators.  Foreign institutions are not eligible for an R03 
award.

MECHANISM OF SUPPORT

This PA will use the National Institutes of Health (NIH) research project 
grant (RO1) and small grant (R03) award mechanisms.  Responsibility for the 
planning, direction, and execution of the proposed project will be solely 
that of the applicant.  The total project period for applications submitted 
in response to this PA may not exceed five years for the R01 award and two 
years for the R03 award.

For all R03 applications and for competing R01 applications requesting up to 
$250,000 direct costs per year, specific application instructions have been 
modified to reflect “MODULAR GRANT” and “JUST-IN-TIME” streamlining efforts 
being undertaken at NIH.  More detailed information about modular grant 
applications, including a sample budget narrative justification page and a 
sample biographical sketch, is available via the Internet at: 
http://grants.nih.gov/grants/funding/modular/modular.htm.

Because small grants have special eligibility requirements, application 
formats, and review criteria, applicants are strongly encouraged to consult 
with program staff (listed under INQUIRIES) and to obtain the appropriate 
additional announcements for those grant mechanisms.  Special instructions 
and information for the small grants program is found at: 
http://grants.nih.gov/grants/guide/pa-files/PAR-99-140.html 

RESEARCH OBJECTIVES

Background

The impact of mental health problems upon the lives of people and nations 
long has been profoundly underestimated.  A recent landmark study (the Global 
Burden of Disease study, conducted by the World Health Organization, the 
World Bank, and Harvard University in 1996) provided a new perspective on 
this impact.  Major depression alone ranked second only to ischemic heart 
disease in magnitude of disease burden in established market economies, such 
as the United States.  Other kinds of mental illnesses also contributed to 
the burden represented by mental illness.

“Mental Health: A Report of the Surgeon General,” published in 1999, 
documents the enormous public health burden of mental disorders in the United 
States, reviews the scientific progress in understanding, treating, and 
preventing these disorders, and points out the barriers to further progress 
in reducing the toll of mental disorders.  A clear message of this report is 
that a variety of well-established treatments are available for the range of 
mental and behavioral disorders that occur across all ages and that everyone 
should be encouraged to seek help for mental health problems just as for 
other health problems.

Much of the personal and societal burden of mental disorders could be 
alleviated if people experiencing these disorders sought and received 
appropriate treatments.  However, the Surgeon General’s report acknowledged 
the existence of major barriers that deter people from accessing treatment.  
For the United States as a whole, these barriers are primarily insurance, 
availability and stigma.  More than 44 million Americans are without any 
health care insurance, and even those who have insurance coverage find that 
mental health benefits are much more restrictive than those for other types 
of illnesses.  For example, current mental health outpatient visits provide 
only about 50 percent co-payment (compared to 85 to 90 percent for all other 
illnesses), and in most private insurance plans, the annual number of 
outpatient visits allowed for mental health treatment is often restricted.

For many years, Americans viewed mental illness as a stigmatized condition.  
While this attitude is slowly being replaced by a more scientific 
understanding, stigma is still a powerful barrier to people seeking help for 
mental disorders and is reflected in the public’s reluctance to pay for 
mental health treatments, particularly through insurance premiums or taxes.

Nearly 60 million Americans living in rural and frontier America have the 
same kinds of mental and general health problems and needs for services as 
individuals who live in urban and suburban areas.  However, in addition to 
the access barriers discussed above that affect all Americans, individuals 
living in underserved rural and frontier areas encounter numerous additional 
barriers to the receipt of effective services.  Access to and availability of 
mental health specialists, such as psychiatrists and psychologists is 
seriously lacking.  Poverty, geographic isolation and cultural differences 
further hinder the amount and quality of mental health care available to 
people in rural areas.

More than 800 rural counties have high poverty rates, but only 25 percent of 
people living in rural areas qualify for Medicaid, compared to 43 percent in 
urban areas. Women head 46 percent of rural households, and, of these 
families, 27 percent are below the poverty level, compared to 9% of male-
headed rural families. The elderly are represented disproportionately in 
rural areas. As Mentioned above, most rural counties have no practicing 
psychiatrists, psychologists or social workers, and providers with formal 
mental health training prescribe only 20 percent of psychotrophic 
medications. In sum, availability of, and access to, mental health 
specialists (and often any kind of provider) remains a serious problem.  
Geographic location creates problems in delivering services in less densely 
populated rural and even more sparsely populated frontier areas.  Questions 
have been raised about whether providers who are available are also 
adequately trained to deliver culturally sensitive care to different groups 
residing in these communities. Cultural barriers may exist to the extent that 
rural America still reflects different values and lifestyles than urban 
America.

These and many other inequities in rural and frontier populations, as well as 
the lack of mental health and health care services, have led members of 
Congress to urge both parity in mental health insurance coverage and greater 
parity in providing mental health services to rural and frontier populations.

Recent changes in the health care system (including managed care) that 
emphasizes cost containment could further imperil access to mental health 
services for people in rural and frontier areas.  There is concern that, in 
the effort to trim the health care costs, rural mental health services could 
continue to suffer disproportionately.  There is a continuing need for 
studies that will assess and monitor the availability and quality of mental 
health services for people in rural and frontier areas.

Listed below are examples of important research topics that need to be 
addressed in order to provide new knowledge on rural and frontier mental 
health problems and how to deliver cost effective care.  This list is 
illustrative, but not exhaustive.  It is expected that researchers who 
respond to this announcement will identify additional research questions that 
will assess how to intervene to enhance the delivery of mental health care to 
a variety of rural and frontier populations.

o  Studies of the incidence and prevalence of mental disorders for children 
and adults (including co-occurring substance disorders) and associated 
disability in diverse rural and frontier settings with special attention to 
underserved populations (e.g., American Indians, Alaska Natives, African-
Americans, Hispanics, the elderly, and those living in poverty).  What are 
the salient program characteristics that are most likely to ensure successful 
provision of preventive interventions and treatment for persons with mental 
illness in diverse rural and frontier settings?

o  Research on barriers to care (community/structural, geographic, cultural, 
and financial) with special emphasis on studies of specific interventions 
designed to overcome such barriers.  What are specific program 
characteristics (including community based outreach efforts) that are crucial 
to overcoming access barriers and enhancing delivery of mental health 
services?  Can mental health care be delivered at least as effectively 
through telecommunications as it is delivered face-to-face?  Does 
effectiveness of long distance care vary by disorder or severity of disorder?  
How significant is cultural competency in the delivery of effective care 
through telecommunications?  What can be done to minimize stigma in 
underserved populations?

o  Studies of preventive interventions in rural and frontier communities.  
How effective are community outreach programs in overcoming stigma and 
encouraging individuals to seek mental health care?

o  Studies of the availability and effectiveness of psychosocial 
rehabilitation services particularly for persons with severe mental 
disorders.  What are the characteristics of successful models that have been 
adapted to rural and frontier areas?

o  Studies of the organization and financing (including private and public 
sectors) of care and how they affect access to and outcomes of care.

o  Studies of mental health care delivery by primary care providers, social 
workers, psychiatric nurses and primary care providers to improve access to 
care and enhance the quality of care?  How can communities integrate the work 
of mental health specialists, primary care providers and other types of 
providers in order to enhance access and the effectiveness of outcomes of 
care?

o  Research on the effect of cost-containment strategies and managed care on 
the mental health care available in rural and frontier areas.

o  Research on social and environmental crises in rural communities and the 
mental health consequences.  How can we intervene to assist families in 
crisis and prevent violence in diverse family groups in rural areas?

o  Research on the reliability and validity of current diagnostic instruments 
used with diverse cultural groups in rural and frontier areas.

o  Research on the design, measurement, and statistical challenges inherent 
in conducting research in rural and frontier communities, including how the 
concept of rural should be defined and operationalized in order to provide a 
context within which investigators can determine meaningful rural/urban 
comparisons.

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of the NIH that women and members of minority groups and 
their subpopulations must be included in all NIH supported biomedical and 
behavioral research projects involving human subjects, unless a clear and 
compelling rationale and justification is provided that inclusion is 
inappropriate with respect to the health of the subjects or the purpose of 
the research.  This policy results from the NIH Revitalization Act of 1993 
(Section 492B of Public Law 103-42).

All investigators proposing research involving human subjects should read the 
“NIH Guidelines For Inclusion of Women and Minorities as Subjects in Clinical 
Research,” which have been published in the Federal Register of March 28, 
1994 (FR 59 14508-14513) and in the NIH Guide for Grants and Contracts, Vol. 
23, No. 11, March 18, 1994 available on the web at the following URL address:
http://grants.nih.gov/grants/guide/notice-files/not94-100.html

INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of NIH that children (i.e., individuals under the age of 21) 
must be included in all human subjects research, conducted or supported by 
the NIH, unless there are scientific and ethical reasons not to include them.  
This policy applies to all initial (Type 1) applications submitted for 
receipt dates after October 1, 1998.

All investigators proposing research involving human subjects should read the 
“NIH Policy and Guidelines on the Inclusion of Children as Participants in 
Research Involving Human Subjects” that was published in the NIH Guide for 
Grants and Contracts, March 6, 1998, and is available at the following URL 
address: http://grants.nih.gov/grants/guide/notice-files/not98-024.html

Investigators also may obtain copies of these policies from the program staff 
listed under INQUIRIES.  Program staff may also provide additional relevant 
information concerning the policy.

APPLICATION PROCEDURES

Applicants are strongly encouraged to contact the program contacts listed 
under INQUIRIES with any questions regarding their proposed project and the 
goals of this PA.

Applications are to be submitted on the grant application form PHS 398 (rev. 
4/98) and will be accepted at the standard application deadlines as indicated 
in the application kit.  Application kits are available at most institutional 
offices of sponsored research and from the Division of Extramural Outreach 
and Information Resources, National Institutes of Health, 6701 Rockledge 
Drive, MSC 7910, Bethesda, MD 20892-7910, telephone (301) 435-0714, Email: 
GrantsInfo@nih.gov.  Applications are also available on the World Wide Web 
at: http://grants.nih.gov/grants/forms.htm.

SPECIFIC APPLICATION INSTRUCTIONS FOR MODULAR GRANTS

The modular grant concept establishes specific modules in which direct costs 
may be requested as well as a maximum level for requested budgets.  Only 
limited budgetary information is required under this approach.  The just-in-
time concept allows applicants to submit certain information only when there 
is a possibility for an award.  It is anticipated that these changes will 
reduce the administrative burden for the applicants, reviewers and Institute 
staff.  The research grants application form PHS 398 (rev. 4/98) is to be 
used in applying for these grants, with the modifications noted below.

BUDGET INSTRUCTIONS

Modular Grant applications will request direct costs in $25,000 modules, up 
to a total direct cost request of $250,000 per year.  (Applications that 
request more than $250,000 direct costs in any year must follow the 
traditional PHS 398 application instructions).  The total direct costs must 
be requested in accordance with the program guidelines and the modifications 
made to the standard PHS 398 application instructions described below.

PHS 398

o FACE PAGE: Items 7a and 7b should be completed, indicating Direct Costs (in 
$25,000 increments up to a maximum of $250,000) and Total Costs {Modular 
Total Direct plus Facilities and Administrative (F&A) costs} for the initial 
budget period Items 8a and 8b should be completed indicating the Direct and 
Total Costs for the entire proposed period of support.

o  DETAILED BUDGET FOR THE INITIAL BUDGET PERIOD – Do not complete Form Page 
4 of the PHS 398.  It is not required and will not be accepted with the 
application.

o  BUDGET FOR THE ENTIRE PROPOSED PERIOD OF SUPPORT – Do not complete the 
categorical budget table on Form Page 5 of the PHS 398.  It is not required 
and will not be accepted with this application.

o  NARRATIVE BUDGET JUSTIFICATION – Prepare a Modular Grant Budget Narrative 
page.  (See http://grants.nih.gov/grants/funding/modular/modular.htm for 
sample pages.)  At the top of the page, enter the total direct costs 
requested for each year.  This is not a Form page.

o  Under Personnel, list key project personnel, including their names, 
percent of effort, and roles on the project.  No individual salary 
information should be provided.  However, the applicant should use the NIH 
appropriation language salary cap and the NIH policy for graduate student 
compensation in developing the budget request.

For Consortium/Contractual costs, provide an estimate of total costs (direct 
plus facilities and administrative) for each year, each rounded to the 
nearest  $1,000.  List the individuals/organizations with whom consortium or 
contractual arrangements have been made, the percent effort of key personnel, 
and the role on the project.  Indicate whether the collaborating institution 
is foreign or domestic.  The total cost for a consortium/contractual 
arrangement is included in the overall requested modular direct cost amount.  
Include the Letter of Intent to establish a consortium.

Provide an additional narrative budget justification for any variation in the 
number of modules requested.

o  BIOGRAPHICAL SKETCH – The Biographical Sketch provides information used by 
reviewers in the assessment of each individual’s qualifications for a 
specific role in the project, as well as to evaluate the overall 
qualifications of the research team.  A biographical sketch is required for 
all key personnel, following the instructions below.  No more than three 
pages may be used for each person.  A sample biographical sketch may be 
viewed at:
http://grants.nih.gov/grants/funding/modular/modular.htm

-Complete the educational block at the top of the form page;
-List position (s) and any honors
-Provide information, including overall goals and responsibilities, on 
research projects ongoing or completed during the last three years.
-List selected peer-reviewed publications, with full citations;

o CHECKLIST – This page should be completed and submitted with the 
application.  If the F&A rate agreement has been established, indicate the 
type of agreement and the date.  All appropriate exclusions must be applied 
in the calculation of the F&A costs for the initial budget period and all 
future budget years.

o  The applicant should provide the name and phone number of the individual 
to contact concerning fiscal and administrative issues if additional 
information is necessary following the initial review.

Applicants planning to submit an investigator-initiator new (type 1), 
competing continuation (type 2), competing supplement, or any amended revised 
version of the preceding grant application types requesting $500,000 or more 
in direct costs for any year are advised that he or she must contact the 
Institute program staff before submitting the application, i.e., as plans for 
the study are being developed.  Furthermore, the applicant must obtain 
agreement from the Institute staff that the Institute will accept the 
application for consideration for award.  Finally, the applicant must 
identify, in a cover letter sent with the application, the staff member and 
Institute who agreed to accept assignment of the application.

This policy requires an applicant to obtain agreement for acceptance of both 
any such application and any such subsequent amendment.  Refer to the NIH 
Guide for Grants and Contracts, March 20, 1998 at 
http://grants.nih.gov/grants/guide/notice-files/not98-030.html

Any application subject to this policy that does not contain the required 
information in a cover letter sent with the application will be returned to 
the applicant without review.

The title and number of the program announcement must be typed on line 2 of 
the face page of the application form and the YES box must be marked.

Submit a signed, typewritten original of the application, including the 
Checklist, and five signed photocopies in one package to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF MENTAL HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710
BETHESDA, MD 20892-7710
BETHESDA, MD  20817 (for express/courier service)

REVIEW CONSIDERATIONS

Applications will be assigned on the basis of established PHS referral 
guidelines.  Applications will be evaluated for scientific and technical 
merit by an appropriate scientific review group convened in accordance with 
the standard NIH peer review procedures.  As part of the initial merit 
review, all applications will receive a written critique and undergo a 
process in which only those applications deemed to have the highest 
scientific merit, generally the top half of applications under review, will 
be discussed, assigned a priority score, and receive a second level review by 
the appropriate national advisory council or board.

Review Criteria

The goals of NIH-sponsored research are to advance our understanding of 
biological systems, improve the control of disease, and enhance health.  In 
the written comments reviewers will be asked to discuss the following aspects 
of the application in order to judge the likelihood that the proposed 
research will have a substantial impact on the pursuit of these goals.  Each 
of these criteria will be addressed and considered in assigning the overall 
score, weighting them as appropriate for each application.  Note that the 
application does not need to be strong in all categories to be judged likely 
to have major scientific impact and thus deserves a high priority score.  For 
example, an investigator may propose to carry out important work that by its 
nature is not innovative but is essential to move a field forward.

(1) Significance:  Does this study address an important problem?  If the aims 
of the application are achieved, how will scientific knowledge be advanced?  
What will be the effect of these studies on the concepts or methods that 
drive this field?

(2) Approach:  Are the conceptual framework, design, methods, and analyses 
adequately developed, well integrated, and appropriate to the aims of the 
project?  Does the applicant acknowledge potential problem areas and consider 
alternative tactics?

(3) Innovation:  Does the project employ novel concepts, approaches or 
methods?  Are the aims original and innovative?  Does the project challenge 
existing paradigms or develop new methodologies or technologies?

(4) Investigator:  Is the investigator appropriately trained and well suited 
to carry out this work?  Is the work proposed appropriate to the experience 
level of the principal investigator and other researchers (if any)?

(5) Environment:  Does the scientific environment in which the work will be 
done contribute to the probability of success?  Do the proposed experiments 
take advantage of unique features of the scientific environment or employ 
useful collaborative arrangements?  Is there evidence of institutional 
support?

In addition to the above criteria, in accordance with NIH policy, all 
applications will also be reviewed with respect to the following:

o  The adequacy of plans to include genders, minorities and their subgroups, 
and children as appropriate for the scientific goals of the research.  Plans 
for the recruitment and retention of subjects will also be evaluated.

o  The reasonableness of the proposed budget and duration in relation to the 
proposed research

o  The adequacy of the proposed protection for humans, animals or the 
environment, to the extent they may be adversely affected by the project 
proposed in the application.

AWARD CRITERIA

Applications will compete for available funds with all other recommended 
applications.  The following will be considered in making funding decisions: 
Quality of the proposed project as determined by peer review, availability of 
funds, and program priority.

INQUIRIES

Inquiries are encouraged.  The opportunity to clarify any issues or questions 
from potential applicants is welcome.

Direct inquiries regarding programmatic issues to:

Anthony Pollitt, Ph.D.
Office of Rural Mental Health Research
National Institute of Mental Health
6001 Executive Boulevard, Room 7130 MSC 9631
Bethesda, MD 20892-9631
Telephone:  (301) 443-4525
FAX:  (301) 443-4045
Email:  apollitt@nih.gov

Direct inquiries regarding fiscal matters to:

Diana S. Trunnell
Grants Management Branch
National Institute of Mental Health
6001 Executive Boulevard, Room 6115 MSC 9605
Bethesda, MD 20892-9605
Telephone:  (301) 443-3065
FAX:  (301) 443-6885
Email:  Diana_Trunnell@nih.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance No. 
93.242.  Awards are made under authorization of the Public Health Service 
Act, Title IV, Part A (Public Law 78-410), as amended by Public Law 99-158, 
42 USC 241 and 285) and administered under PHS grants policies and Federal 
Regulations 42 CFR and 45 CFR Part 74.  This program is not subject to the 
intergovernmental review requirements of Executive Order 12372 or Health 
Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a 
smoke-free workplace and promote the non-use of all tobacco products.  In 
addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking 
in certain facilities (or in some cases, a portion of a facility) in which 
regular or routine education, library, day care, health care or early 
childhood development services are provided to children.  This is consistent 
with the PHS mission to protect and advance the physical and mental health of 
the American people.

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