Research on Mental Health and Substance Use Disorders in Rural Populations

Research on Mental Health and Substance Use Disorders in Rural Populations is sponsored by National Institutes of Health (NIH). Supports research on mental health and substance use disorders in rural populations.

Expired PA-06-478: Research on Rural Mental Health and Drug Abuse Disorders (R01) This notice has expired. Check the NIH Guide for active opportunities and notices. Part I Overview Information Department of Health and Human Services Participating Organizations National Institutes of Health (NIH), ( http://www.

nih. gov ) Components of Participating Organizations National Institute of Mental Health (NIMH), ( http://www. nimh.

nih. gov ) National Institute on Drug Abuse (NIDA), ( http://www. nida.

nih. gov ) on Rural Mental Health and Drug Abuse Disorders (R01) This is a reissue of PA-04-061 , which was previously issued on February 12, 2004. Update: The following update relating to this announcement has been issued: December 4, 2006 - The R01 portion of this funding opportunity has been replaced by PA-07-103 , which now uses the electronic SF424 (R&R) application for February 5, 2007 submission dates and beyond.

Looking Ahead: As part of the Department of Health and Human Services' implementation of e-Government, during FY 2006 the NIH will gradually transition each research grant mechanism to electronic submission through Grants. gov and the use of the SF 424 Research and Related (R&R) forms.

Therefore, once the transition is made for a specific grant mechanism, investigators and institutions will be required to submit applications electronically using Grants. gov. For more information and an initial timeline, see http://era. nih.

gov/ElectronicReceipt/ . NIH will announce each grant mechanism change in the NIH Guide to Grants and Contracts ( http://grants. nih.

gov/grants/guide/index. html ). Specific funding opportunity announcements will also clearly indicate if Grants.

gov submission and the use of the SF424 (R&R) is required. Investigators should consult the NIH Forms and Applications Web site ( http://grants. nih.

gov/grants/forms. htm ) for the most current information when preparing a grant application. Program Announcement (PA) Number: Catalog of Federal Domestic Assistance Number(s) Release Date: July 7, 2006 Letters of Intent Receipt Date(s): Not applicable.

Application Submission Date(s): Standard dates apply, please see http://grants1. nih. gov/grants/funding/submissionschedule.

htm AIDS Application Receipt Date(s): See http://grants1. nih. gov/grants/funding/submissionschedule.

htm#AIDS Peer Review Date(s): See http://grants1. nih. gov/grants/funding/submissionschedule.

htm#reviewandaward . Council Review Date(s): See http://grants1. nih.

gov/grants/funding/submissionschedule. htm#reviewandaward . Earliest Anticipated Start Date: See http://grants1.

nih. gov/grants/funding/submissionschedule. htm#reviewandaward .

Additional Information To Be Available Date (Url Activation Expiration Date for R01 Non-AIDS Applications : November 2, 2006 Expiration Date for R01 AIDS and AIDS-Related Applications : January 3, 2007 Additional Overview Content The purpose of this Funding Opportunity Announcement (FOA) is to invite grant applications to stimulate research on mental health and/or drug abuse problems in rural and frontier communities that will: (1) enhance understanding of structural (including community risk and resilience factors), cultural, and individual factors that may enhance the provision and utilization of prevention and treatment services in these communities; and (2) generate knowledge to improve the organization, financing, efficiency, effectiveness, quality, and outcomes of mental health and drug abuse services for diverse populations in rural and frontier populations.

Because the nature and scope of the proposed research will vary from application to application, it is anticipated that the size and duration of each award will also vary. The total amount awarded and the number of awards will depend upon the quality, duration, costs, as well as the number of applications received.

Funding decisions will reflect the needs, priorities and mission of the funding This FOA will use the NIH Research Project Grant (R01), but applications for the NIMH Clinical Exploratory/Developmental Research Grant (R34) are also encouraged.

Applicants for the R34 mechanism must submit their applications electronically and should respond to the NIMH Parent FOA for this mechanism Eligible organizations include for-profit organizations, non-profit organizations, public or private institutions, such as universities, colleges, hospitals, and laboratories, units of State government, units of local government, eligible agencies of the Federal government, non-domestic institutions, domestic Institutions, faith-based or community-based organizations, Indian/Native American Tribal Government (Federally Recognized), Indian/Native American Tribal Government (Other than Federally Recognized), and Indian/Native American Tribally Designated Any individual with the skills, knowledge, and resources necessary to carry out the proposed research is invited to work with their institution to develop an application for support.

Applicants may submit more than one application, provided they are scientifically See Section IV. 1 for application materials. Telecommunications for the hearing impaired is available at: TTY 301-451-5936.

Part I Overview Information Part II Full Text of Announcement Section I. Funding Opportunity Section II. Award Information Section III.

Eligibility Information 2. Cost Sharing or Matching 3. Other - Special Eligibility Criteria Section IV.

Application and Submission 1. Address to Request Application Information 2. Content and Form of Application Submission 3.

Submission, Dates and Times A. Submission, Review and Anticipated B. Sending an Application to the C.

Application Processing 4. Intergovernmental Review 6. Other Submission Requirements Section V.

Application Review 2. Review and Selection Process A. Additional Review Criteria B.

Additional Review Considerations D. Sharing Research Resources 3. Anticipated Announcement and Award Dates Section VI.

Award Administration 2. Administrative and National Policy Requirements Section VII. Agency Contact(s) 1.

Scientific/Research Contact(s) 2. Peer Review Contact(s) 3. Financial/ Grants Management Contact(s) Section VIII.

Other Information - Required Federal Citations Section VIII. Other Information - Required Federal Citations Part II - Full Text of Announcement Section I.

Funding Opportunity Description The National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) invite grant applications for research that will ultimately lead to a reduction in the burden of mental illness and drug abuse in rural and frontier populations.

The purpose of this Funding Opportunity Announcement (FOA) is to stimulate research on mental health and/or drug abuse problems in rural and frontier communities that will: (1) enhance understanding of structural (including community risk and resilience factors), cultural, and individual factors that may enhance the provision and utilization of prevention and treatment services in these communities; and (2) generate knowledge to improve the organization, financing, efficiency, effectiveness, quality, and outcomes of mental health and drug abuse services for diverse populations in rural and frontier populations.

Applications may focus exclusively on mental disorders, drug abuse disorders, or on the co-occurrence of these and related disorders. Comparisons of rural and urban populations and/or comparisons between rural populations is encouraged, whenever possible, but this is not a requirement. The impact of mental illness and drug abuse upon the lives of people and nations has been profoundly underestimated and under-appreciated.

A 2003 report from the President’s New Freedom Commission on Mental Health ( http://www. mentalhealthcommission. gov ) and other reports such as, Mental Health: A Report of the Surgeon General, (1999) ( http://www.

nimh. nih. gov/research/sgreports.

cfm ), document the enormous public health burden of mental health and co-occurring disorders in the United States. Much of the personal and societal burden of mental and drug abuse disorders could be prevented or alleviated if people at-risk for experiencing these disorders sought and received appropriate prevention and treatment interventions.

These reports note that barriers such as limited insurance coverage, scarce availability of services, and stigma must be overcome in order to achieve further progress in preventing and reducing the toll of mental health and drug abuse disorders. Other barriers such as lack of community resources and distance contribute to the lack of adequate prevention approaches in many rural areas.

Much scientific progress has been made in understanding, treating, and preventing mental health and drug abuse disorders, and in understanding their emotional and financial costs to families and society. A variety of well-established prevention and treatment interventions are available for the range of mental, emotional, and drug-abuse problems that occur across all ages, racial and ethnic groups, and gender.

However, these interventions are not reaching many who need them. See, for example, Years 2004-2008; also An Investment in America’s Future- Racial/Ethnic Diversity in Mental Health Careers, NIMH National Advisory Mental Health Research Careers, The President’s New Freedom Commission Report noted that the public health burden of mental illness and drug abuse is great.

Approximately 5% to 7% of adults have a serious mental disorder in any given year, and about 5% to 9% of children have a serious emotional illness. This means that millions of individuals are afflicted each year. The annual economic cost of these illnesses is estimated at $79 billion.

Approximately $63 billion of this reflects lost productivity; mortality costs are $12 billion due to premature death, and almost $4 billion are attributed to productivity losses due to incarceration and the provision of family care. In the last 15 years, mental health spending has not kept pace with general health care. In 1997, the United States spent more than $1 trillion on health care.

This included $71 billion to treat mental illnesses. The public health burden of drug abuse is also great, particularly in association with HIV-risk behavior, smoking, criminal activity, lost work productivity, interrupted educational careers, family violence, and other adverse health outcomes. The most recent findings from the National Survey on Drug Use and Health found that in 2003, more than 8.

2% of Americans age 12 and older had used an illicit drug within the past month. Methamphetamine use is becoming a major problem in rural/frontier communities. Despite the fact that effective prevention and treatment interventions exist to combat the behaviors and effects of drug use and abuse, too few individuals are provided with effective interventions.

For example, for many of those who do receive treatment, the care provided is often inadequate not intensive enough, not long enough, or lacking in important supportive health and social Although inconclusive, research evidence suggests that the prevalence and incidence of mental illness and drug abuse for adults and children are similar for rural and urban populations.

Suicide rates differ in these communities, however, with rural suicide rates exceeding urban rates. Much of the personal and societal burden of these disorders could be alleviated if people experiencing one or more of them sought and received appropriate treatment. However, research has shown that major barriers deter many individuals from entering treatment.

For the United States as a whole, these barriers are primarily stigma, lack of parity placed on mental health and drug abuse insurance benefits in private health care, and a fragmented system of care. An estimated 45 million Americans are without any health care coverage. For those with insurance, mental illness and drug abuse visits carry a patient co-payment of about 50%, compared to 10% to 15% for other illnesses.

Stigma remains a powerful barrier to people seeking help for mental illness and drug addiction, and stigma is also reflected in the public’s reluctance to pay for treatments, particularly through insurance Nearly 60 million Americans living in rural and frontier communities face additional barriers to receiving effective prevention and treatment services for mental health and drug abuse problems.

Access to and availability of mental health and drug abuse specialists, such as psychiatrists, psychologists, and social workers appear to be seriously lacking. Poverty, geographic isolation, and cultural differences further limit the amount and quality of mental health care and drug abuse prevention and treatment services available to individuals in rural and frontier areas.

This means that rural residents often enter care later in the course of their illness than their urban peers, enter care with more serious symptoms, and require more intensive and expensive treatment. Moreover, the cost of services especially prescription medications- may be too high for many rural (as well as urban) Americans.

The President’s 2003 report suggests, Affordable and accessible transportation services may be unavailable, especially to rural children, the disabled, and the elderly. And, rural residents have longer periods without insurance coverage than their urban peers, and they are less likely to seek services when they cannot pay.

Questions also arise about whether available providers are adequately trained to deliver culturally sensitive care to different groups living in these communities.

Primary care physicians are often the only providers of mental health and drug abuse services in rural communities, and many of them have not been trained and/or do not have the time to adequately treat these Recent changes in the health care system (including managed care) that emphasize cost containment could further imperil access to mental health and drug abuse prevention and treatment services for people in rural and frontier areas.

There is concern that, in the effort to trim health care costs, rural services could suffer disproportionately. There is a continuing need for studies to assess and monitor the availability, accessibility, quality and outcomes of mental health and drug abuse services for individuals in rural Areas of Research Opportunities The following list of potential research topics is illustrative, not exhaustive.

Researchers responding to this funding opportunity announcement are invited to identify additional areas of inquiry that, when explored, will lead to the enhancement of the delivery of mental health and drug abuse prevention and treatment services to diverse rural and frontier populations.

Moreover, given that many health care needs are developmentally-based, gender-based, and culturally/technically-based, and given the growing body of research indicating developmental, gender, and ethnic differences in the developmental trajectories of mental health and drug abuse problems, researchers are encouraged to take developmentally-based, gender-based, and culturally-based approaches (including evidence-based practices) in designing their research and proposing hypotheses.

Researchers are also encouraged to explore community-based participatory research areas that involve community and academic partners as research collaborators.

The 1999 National Advisory Mental Health Council (NAMHC) Report, Bridging Science and Services, highlights several recommendations focused on increasing academic-community partnerships in research Several methodological issues challenge researchers seeking to study the provision of health services in rural and frontier communities.

Although rural typologies have been devised to guide researchers and policy makers, they often fail to capture the relationship between (rural/frontier) population characteristics that are relevant to mental health service and drug abuse treatment outcomes.

Statistical definitions, for example, have been used for implementing public policy, but the term rural, operationalized by these definitions, is only a proxy variable for identifying differences in availability, access, need, and use of services.

When current definitions are used to design and assess mental health and drug abuse services, it is impossible to differentiate why a particular intervention is effective in one rural community and not another. Rural and frontier studies also often encounter difficulty in obtaining a sufficient sample size and thus lack the power to allow community to be utilized as an explanatory variable.

Investigators are encouraged to consider promising methodologies that would include: multi-level studies that would represent individuals within communities and communities within regions or geographic entities; multivariate analysis, including structural equations modeling; and state-of-the-art methods for analyzing small samples as well as longitudinal data.

Investigators are encouraged to identify or New rural typologies that capture the relationship between (rural/frontier) population characteristics that are relevant to mental health service and drug abuse treatment outcomes. New definitions of rural that include various ecocultural characteristics operationalizing the cost of space for rural populations under investigation.

Ecology might include the resources and constraints of a community, including level and rate of economic development, dependability and consistency of economic resources; service use, social support and social networks, and factors that promote risk and resilience for individuals and families. Culture might include the beliefs and values that influence community decisions and demographics including racial/ethnic diversity.

Analytic strategies for overcoming the problems posed by small sample sizes. Analyses of rural and frontier populations are needed to enhance the knowledge base about the prevalence of mental/drug abuse disorders and access to mental health/drug abuse prevention and treatment services in children and older adults.

Results from available studies suggest that there is no difference in the prevalence of psychiatric disorders between metropolitan and non-metropolitan adults; however these results may be outdated due to demographic changes in rural areas and how rural is defined and measured. Existing studies also shed little light on intra-rural differences in the prevalence of psychiatric and drug abuse disorders.

Similarly, little is known about differences in these disorders among rural and urban children. Thus, investigators are encouraged to: Conduct meta-analyses of the epidemiology of mental health and drug abuse disorders in rural areas, using existing databases to inform the development of a typology that identifies rural communities at high risk of disorder/under utilization of services.

It may be useful to supplement selected existing databases with community-level variables to examine social and economic predictors of intra-rural variation. Analyze the factors associated with both the risk and resilience of families and individuals in diverse communities.

Build on the identification of high-risk areas nationwide through regional epidemiological studies of prevalence, service capacity, use of care, etc., to inform policy decisions about service provision to high-risk Exploration of behavioral epidemiology of factors associated with adverse mental and physical health outcomes, including substance use, HIV/STD risk behavior, and treatment adherence.

Conduct social network analyses in rural settings that enhance prevention of HIV/STD transmission, particularly among isolated communities with low HIV/STD risk perceptions. 3) Demand and Need for Care Research is needed to identify factors that predict why some individuals recognize and accept the need for mental health care and/or drug abuse treatment and enter appropriate treatment.

Metropolitan and non-metropolitan persons with psychiatric and drug abuse disorders have been reported as having comparable entry rates into care, though both populations have relatively low rates of entry into care. Some investigators have reported that rural residents are less likely than urban individuals to enter care, but these findings are difficult to interpret because they do not control for need.

There is evidence that individuals in rural communities are more likely than their urban counterparts to use primary care providers, particularly if they are poor, a member of racial and ethnic groups, women and children, the elderly, individuals with substance abuse problems, or the severely mentally ill.

Investigators are encouraged to: Analyze how the following factors impact perceived access, need, and demand for care by rural at-risk individuals in high-risk communities: stigma, perceived service availability, accessibility, affordability, perceived communication, and cultural sensitivity of providers Test the effectiveness of interventions designed to heighten awareness of need for care, and the effectiveness of evidenced-based treatment, such as direct marketing and social network interventions.

Design research to study mechanisms that enhance and impede the dissemination and translation of research findings on mental health and drug abuse services into rural communities. Analyze how health interventions designed for, and shown efficacious in, urban settings address the prevention needs of rural and small city populations.

Incorporate risk screening and prevention counseling into routine clinical care, STD clinics, substance abuse treatment, prenatal care or other medical settings, and study the feasibility, utilization, efficacy, and effectiveness of these health promotion interventions for rural populations.

4) Socio-cultural Beliefs About Mental Illness, Drug Addiction, and Disparities in Use of Mental Health and Drug Treatment Services Rural and frontier communities are no longer viewed as being homogeneous, as more individuals from various racial and ethnic groups migrate to rural communities. Addressing these demographic changes is crucial to the delivery of effective health care.

Research evidence suggests that cultural beliefs and values may shape one’s definitions of mental illness and drug abuse and influence one’s decision to seek formal or informal care and complete care. For example, studies have found that depressed and suicidal farmers are often reluctant to seek help because of their strongly-held values of self-reliance and concerns about confidentiality.

Other studies suggest that members of ethnic and racial groups often may not seek care for mental illness or drug abuse due to distrust of outsiders, discrimination, religion, or a sense of fatalism. Investigators are encouraged to: community readiness to identify and address mental health, health risk, and drug abuse problems; and care needs; and to develop appropriate responses and deliver effective interventions.

Analyze various community partnership processes required to identify mental illness, drug abuse, and related health problems and develop appropriate responses leading to the delivery of effective interventions and outcomes of care. Analyze the socio-cultural factors that predict use of mental health and drug abuse services in rural areas, including the distribution of these factors across racial/ethnic groups.

Study the socio-cultural beliefs about mental illness, drug abuse, and treatment that influence how people of various racial and ethnic groups seek care; the cultural beliefs practitioners bring to the clinical encounter; and how these beliefs affect clients decisions to use or continue Develop research to test interventions that improve the quality and outcomes of mental health services in culturally diverse populations.

Analyze factors that influence the efficacy of treatment and prevention interventions within a specific racial or ethnic group, and the adaptability of successful interventions to other racial or ethnic groups Design research to study the impact of severe psychological trauma on different subpopulations in the rural U.S., especially racial and ethnic groups, including how, if at all, trauma affects drug use and abuse, treatment seeking behavior, and retention in treatment.

Study the impact of social and community norms on the effectiveness of prevention programs that target socially sensitive health Design research to study the prevention needs of seasonal migrant populations, who may experience acute isolation, drug abuse problems, lack of access to mental health care or drug treatment, and considerable social, economic, and language barriers affecting mental health care utilization and public health in rural settings.

5) Access to and Quality of Care Investigators have raised questions about whether specific aspects of rural life contribute to differences in access to and quality of mental health care and substance abuse treatment among rural communities and between rural and urban communities.

An alternative view is that larger societal and structural factors are responsible for differences in access to and quality of services in rural and frontier areas.

This remains an open question, so investigators are encouraged to: Study the extent to which successful urban and rural interventions for mental health and drug abuse problems have been implemented successfully in diverse rural and frontier communities, and how successful urban/rural interventions can be modified to work most effectively in rural and frontier specialty and non-specialty settings.

Design research to analyze initiatives to improve the quality and outcomes of care for persons with co-morbid psychiatric and Design research to study the type, quality, accessibility, and availability of preventive interventions in rural and frontier communities. Test the effectiveness of family, school, and community programs in addressing prevention in rural specialty and non-specialty settings.

Study the extent to which rural or frontier status increases the effect of known barriers to care in these communities. For example, are the poor, elderly, children, homeless, or racial and ethnic populations in rural communities less likely to have access to treatment, or are less likely to demand, enter, and remain in care than their urban counterparts?

Compare the quality of care delivered in rural and urban communities and determine factors associated with discrepancies in quality, such as clinicians who may not be providing evidence-based care, individuals who choose not to enter care, or to a combination of other local, regional, Analyze the frequency of use and outcomes of alternative or nontraditional care (e.g., faith-based care) for mental disorders and drug-abuse addiction in rural communities.

Study how to maintain client confidentiality in rural service delivery and research, including: Studying the most effective ways to overcome stigma as a means of helping individuals enter and remain in care until treatment is completed, Analyzing the relation between organizational characteristics (structural and cultural) and the provision of confidential services to rural patients, and Analyzing the relation between organizational and culture issues and the management of care-giving systems and patient utilization of services.

Study the contextual supports necessary to promote compliance with treatment regimens for severely mentally ill (SMI) and drug addicted patients, particularly when they are discharged from care centers that are a great distance from their community and when they live in communities where little or no follow-up care is available.

Define the cultural components of care needed to sustain recovery in the local community, and study interventions that deliver these components to determine their impact on subsequent hospitalization rates for rural SMI and drug addicted clients. Study whether telecommunication technologies can be cost-effectively used to increase access to and availability of and quality care for rural SMI and drug-addicted clients.

Design research to determine if the barriers to disseminating evidence-based care models for SMI and drug-addicted clients in rural areas are related to provider, patient, community factors, or a combination of these factors. [For further discussion of this issue see: Research on Community Reintegration for People with Psychiatric Disabilities PA-06-427 ].

6) Suicide in Rural and Frontier Areas Higher rates of suicide are found in rural versus urban areas. Also, states vary by region, with Western mountain states having the highest rates of suicide in the nation. Investigators Study why rates of suicide are greatest in selected rural states and communities.

Analyze risk and protective factors that explain rural-urban and intra-rural differences in suicide rates, such as psychological and cultural issues, biological and genetic characteristics, access to care by mental health and addictions specialists, etc. Design research to test interventions that address modifiable factors related to suicide risk.

[For further discussion of this issue see: Research on the Reduction and Prevention of Suicidality PA-06-438 ] Study the efficacy of interventions to identify and intervene with socially isolated, rural residents who experience frequent or serious suicidal ideation, particularly among those living with HIV or other health/mental health conditions that lead to increased life stress.

7) Economics of Mental Health Care and Drug Abuse Service It is important to determine the impact of different costs and financing models on service delivery in rural and frontier communities. The health care plans for mental health and drug abuse services and the service systems that provide care to rural populations differ from plans and service systems for urban populations.

Rural and frontier populations are less likely to have managed care, and there is a lack of mental health and addiction specialists to provide these specialized services. Studies are sought on the economics of mental health and drug abuse services for treatment and prevention, especially for research on alternative payment systems, public and private financing systems, and the design of insurance.

Investigators are encouraged to: Study the financing of mental health and drug abuse treatment and prevention services in rural and frontier communities, including whether carve-outs differentially affect entry into care or the quality of Analyze alternative delivery systems and managed care practices in rural and frontier communities.

Conduct cost-benefit, cost-effectiveness, and cost-utility analyses to examine the costs and production of mental health and drug abuse treatment and prevention services.

[More information on NIDA’s program of research on the economics of drug abuse prevention or treatment is available Compare managed health care plans and services for mental health and drug abuse problems in rural versus Analyze how, if at all, rural/urban differences in credentialing, selective contracting, and risk sharing, moderate the impact of managed health care services for mental health and drug abuse problems.

8) Use of Technological Innovations In the Diagnosis and Rural advocates suggest that the use of telecommunications technology may offer an opportunity to overcome many barriers to service delivery and to enhance the quality of care provided to underserved rural and frontier populations.

However, until there is evidence that services can be effectively delivered via telemedicine, third party payers are unlikely to reimburse for such services.

Investigators are encouraged to: Study the extent to which telecommunications are used in the delivery of mental health care and drug abuse treatment in rural and frontier communities, and study barriers that exist to implementing Study whether individuals with various mental/drug abuse disorders can be effectively diagnosed and treated via telemedicine.

Design research to study whether certain mental and drug abuse disorders are more amenable to effective diagnosis and treatment face-to-face versus long distance, including whether the type of or severity of mental disorders or drug abuse problems influences the effectiveness of 9) Primary Care and Mental Health/Drug Abuse Services Up to 80% of the mental health care in rural communities is delivered by primary care physicians, social workers, and psychiatric nurses.

Availability of and access to mental health and drug addiction specialists remains a serious problem in many places. Several questions have been raised about the effects of provider distribution on the quality and outcomes of care. Studies of primary care providers and mental health/drug abuse treatment are needed to understand several issues.

Thus, investigators are encouraged Study whether rural primary care providers are adequately trained to deliver high quality and effective mental health care and drug abuse treatment services to a range of client populations. Can primary care providers be trained to use mental health and drug addiction guidelines for treating various disorders?

Study whether primary care providers are adequately trained to deliver culturally appropriate care to the increasing number of minority groups moving to rural areas. Study what non-mental health and non-addictions specialists in rural communities can do to increase effective diagnosis and treatment of individuals with mental disorders and drug abuse problems.

10) Juvenile and Adult Justice and Mental Health/Drug Abuse Rural communities are often called upon to respond to mental health and substance needs of offenders identified through the criminal justice system.

In addition to managing the mental health and substance abuse issues of offenders initially entering the juvenile and adult criminal justice systems, rural areas increasingly need to address the treatment and service needs of offenders returning to their communities following incarceration.

Studies are needed to identify, develop, and test other more effective therapeutic strategies for responding to persons in the justice system with mental illness and drug addiction problems who live in these remote areas.

Investigators Conduct research to understand the mental health/drug abuse treatment currently being delivered to mentally ill/substance abusing offenders in rural communities, and how this treatment is linked or coordinated with criminal justice requirements.

Design research to study how rural organizations or agencies dealing with mentally ill/substance abusers can improve their interactions to achieve better public health, public safety, and individual Analyze the role the criminal justice system plays in the delivery and financing of mental health/drug abuse services in rural See Section VIII, Other Information - Required Federal Citations , for policies related to this announcement.

This FOA will use the NIH Research Project Grant (R01) award mechanism. As an applicant, you will be solely responsible for planning, directing, and executing the proposed project. The total