STAFF COMMENTS ON NHI-NIMH CONFERENCE REPORT BEHAVIORAL FACTORS AND CARDIOVASCULAR DISEASE We have carefully studied the conference report of the NHI-NIMH special consultants on behavioral factors and cardiovascular disease. The tone of the report is vigorous, hortatory and frankly action-oriented, and properly so, since it is focused on invigorating the Institutes' approach to a crucial set of overlapping problems, which, because of their overlapping nature, have not previously received appropriate attention. We strongly recommend a second meeting of the original conferees to discuss in greater detail, in real depth, the numerous issues identified at the March meeting, and feel that it would result in a much better program effort. We believe that such a second meeting ought to be backed by staff involvement of a substantive nature, far more than that which took place at the earlier meeting. From our point of view, the conference report does not sufficiently emphasize critical areas--specifically, basic etiological research and conceptual and methodological issues in psychosomatic studies. We feel, furthermore, that it might be premature to launch a crash program now which would focus only on practical problems at the possible expense of continued efforts to unravel basic etiological issues and co investigate fundamental conceptual and methodological questions. In view of the high incidence of cardiovascular disease, the high sudden-death rate from myocardial infarction, and the relevance of psychological factors in the course of the disease and in the rehabilitative process, we feel there is an urgent need for the develop- ment of additional knowledge on the relationship of biobehavioral factors to cardiovascular disease. Our comments on the committee's recommendations follow: RECOMMENDATION 1: AN IMMEDIATE CONCERTED EFFORT SHOULD BE MADE TO ATTEMPT TO APPLY VISCERAL LEARNING TECHNIQUES IN PATIENTS WITH ACUTE CARDIOVASCULAR DISORDERS. THIS SHOULD HAVE THE HIGHEST PRIORITY. Comments What we should like to dofirst is to investigate the area further, and far more thoroughly than we have so far, to determine broadly the range of current support for the area. Through such a study we should like to review carefully the status of research on visceral learning in animals, and try to evaluate the move to human testing in the area. The state of this art, the extent of research currently in progress, the gaps which exist in our understanding here, the limitations of tne technique, and the precise extent of our knowledge have to be critically reviewed as a base for developing a more intense, more focused program of development in this area. It is an area to which the behavioral sciences and NIMH can bring some expertness. We are currently supporting a number of projects in this area and we recommend that NIMH enlist two or three scientists to explore and to critically review results in this area in great detail and report back within six months with recommendations. A quick, but not exhaustive, survey shows several NIMH-supported investigators, other than Neal Miller, working on the problem; some of them are attempting, or proposing to attempt, research on application of instrumental cardiac conditioning 2 to normal humans. Before launching a large program of experiments on human clinical material, however, we feel it would be more appropriate at this time to initiate some small collaborative studies which would test the feasibility of this approach. The application of findings on visceral learning would require enlisting one of the few behavioral scientists who have worked closely with the technique for a collaborative study within a Heart Institute Unit. NIMH might contribute to that by advising and assisting in recruiting the behavioral scientist. RECOMMENDATION 2: A WORKSHOP BE HELD ON THE BEHAVIORAL SCIENCE ASPECTS OF THE STRUCTURAL AND FUNCTIONAL DESIGN OF CORONARY CARE UNITS. Comments Recommendation #2 is highly specific to the needs of the Heart Institute. This goal could probably better be accomplished by the use, as expert consultants, of well-trained and experienced psychiatrists such as Doctors Morton Reiser or Donald Oken. NIMH could provide NHI with a list of such consultants and help in making them available. Appropriate and helpful studies are likely to grow out of such contacts and we think would be of more value than organizing a workshop at this point. RECOMMENDATION 3: THE INSTITUTES SHOULD CONTRACT WITH A GROUP OF BEHAVIORAL SCIENTISTS AND CHARGE THEM WITH THE RESPONSIBILITY TO CENTRALLY DESIGN, PLAN, AND SUPERVISE A STUDY TO BE CARRIED OUT IN CONJUNCTION WITH COOPERATING SURGICAL RESEARCH GROUPS. Comments It is our opinion that the National Heart Institute most properly would take the initiative for studies in surgical units. The NIMH will gladly respond with cooperation and assistance, again, in identifying consultants and possible types of collaborative activity. RECOMMENDATION 4: THE INSTITUTES SHOULD TAKE IMMEDIATE STEPS TO DEVELOP AND MAKE AVAILABLE CONTINUOUS, AUTOMATIC, PORTABLE DEVICE FOR ACCURATELY MEASURING AND RECORDING BLOOD PRESSURES. Comments There is no argument with the need for, and potential value of, the development of an automatic portable device for accurately measuring and recording blood pressures. This recommendation should be actively pursued and would be an excellent arena for collaborative NIMH-NHI efforts. RECOMMENDATION 5: THE NHI AND NIMH SHOULD APPOINT AN AD HOC ADVISORY AND REVIEW COMMITTEE, REPORTING JOINTLY TO BOTH INSTITUTES AND THEIR COUNCILS. Comments This is an excellent idea. Each Institute should assign one staff member to the Committee (2 Executive Secretaries). Applications which incorporate these two elements would be identified within each of the Institutes for referrals. One Executive Secretary from CRB's Psychosomatics Program and one from a comparable Heart Institute Program could serve the Committee. This would permit the current 3 application referral policy to continue as before. A recently-submitted application from Dr. F. Freyhan of St. Vincent's Hospital in New York, on open heart surgery, is a good example of the kind of research referred to under recommendation #3, which could go to this Committee. ADMINISTRATIVE PROBLEMS As the conferees recognized, numerous problems of an administrative nature are involved in the implementation of increased activity in the cardiovascular-biobehavioral research area and we see a need for clearer guidelines, as to review and assignment, a need for demarcation of respective areas of responsibility for the NIMH and the NHI; there is clearly a need for dual assignments of research grant proposals received in the interim. PLANS FOR IMMEDIATE FUTURE Our present plan is to solicit reaction to the report in its present form from selected Institute staff and consultants who have not previously been aware that the conference was held. We also hope to present it to the National Advisory Mental Health Council at its policy meeting in September 1969. ie s Joveces Li lee ae feu woe bw Louis A. Wienckowski, Ph.D. Director Division of Extramural Research Programs National Institute of Mental Health Li attig U- fare cif Betty H. Pickett, Ph.D. Deputy Director Division of Extramural Research Programs . National Institute of Mental Health ~ | _ > Ga v{ LA, eo . ( AD nd x Martin M, Katz, Ph.D. / Chief, Clinical Research Branch Division of Extramural Research Programs National Institute of Mental Health July 17, 1969