The Opening of the Sierra-Pacific Mental Illness Research, Education and Clinical Center (MIRECC)

The Department of Veterans Affairs (VA) has recently developed a program of Mental Illness Research, Education and Clinical Center (MIRECCs). MIRECCs are designed to bring state-of-the-art research, educational and clinical activities to select VA regional areas or Networks. Selected through a national competition, the MIRECC for the Sierra-Pacific Network will join five other similar facilities nationwide and begin operations October 1, 1998. Funding is 1.565M$ per year and is not time-limited.

Dr. Jerome Yesavage, of Veteran’s Affairs Palo Alto Health Care System (VAPAHCS) and Stanford University, will be Director of the MIRECC. The MIRECC will work under the administrative authority of Dr. Robert Wiebe, Director of the Sierra-Pacific Network. Director of Research Activities will be Dr. Charles Marmar of VA Medical Center (VAMC) San Francisco and the University of California at San Francisco. Director of Clinical Activities will be Dr. Javaid Sheikh of VAPAHCS and Stanford University. Director of Educational Activities will be Fred Gusman and of VAPAHCS. Director of Methodology and Evaluation Activities will be Dr. Rudolf Moos VAPAHCS and Stanford University.

The Sierra-Pacific Network has chosen as its overall theme for the MIRECC the matching of treatments for mental illnesses to the personal characteristics of the individual veteran patient. Given the extensive array of behavioral and biological treatments now available for mental illness, the VISN will emphasize how matching specific treatments to individual veterans can improve the quality of care afforded our veteran patients with mental illness.

Focusing first on patients with Post-traumatic Stress Disorder (PTSD) and behavioral problems associated with Alzheimer's Disease and related dementias, MIRECC investigators will build a wide network across Hawaii, Northern California and Nevada to conduct studies matching patients to the best treatment. The characteristics of patients will be assessed using a broad range of neurochemical, neuroimaging and psychosocial measures.

Collaborations involve the University of Hawaii, the University of Nevada at Reno, the University of California at Davis, Fresno and San Francisco, as well as Stanford University. In addition to the clinical and research aspects of the MIRECC, the program will build a new internet-based educational structure using state-of-the-art video streaming technology to bring the latest in medical information to the desktop computers of VA clinicians.

The MIRECC is organized around certain "core" functions or components designed to interact to achieve research, educational and clinical aims.

The PTSD Clinical Core will investigate new pharmacological and psychological treatments for veterans with PTSD. They will focus on relatively underserved populations of veterans with PTSD including women and those with substance abuse problems. This group of investigators will attempt also to gather basic information about why PTSD occurs in some veterans and not in others as well as attempt to gain formation that will help match veterans to the best treatments for their PTSD.

The Dementia Clinical Core will investigate the practical usefulness of new pharmacological treatments for veterans with dementia. In addition, Dr. Javaid Sheikh, the MIRECC’s overall Clinical Director, will focus a number of studies on developing effective pharmacological and behavioral treatments for veterans with dementia who have aggressive outbursts. As in the case of the PTSD studies, this group of investigators will gather information that will help match veterans to the best treatments for their cognitive losses and/or aggressive outbursts.

In addition to the Clinical Cores that focus on clinical research and patient outcomes, three groups of scientists developed three Assessment Cores that will provide state-of-the-art assessments of our veterans using the latest neuroimaging, neurochemical and chronobiological (sleep-related) measures.

The Neuroimaging Core is led by Dr. Michael Weiner of VAMC San Francisco and University of California at San Francisco. This Core will provide a novel centralized processing unit for imaging data collected at all six MIRECC main sites. Dr. Weiner will work with the following collaborators: Dr. Brad Burton, of VAMC Honolulu and the University of Hawaii; Drs. George Fein, Norbert Schuff, Diane Amend and Sean Steinman of VAMC San Francisco and the University of California at San Francisco; Drs. William Jagust, Albert Weinshelbaum and Gail Smith of VANCHCS and the University of California at Davis; Drs. William Vlyman and Sundeep Nayak of VACCHCS and the University of California at San Francisco, Fresno Campus; and Dr. Lee Darrah of VAMC Reno and University of Nevada.

This Core will provide a novel centralized processing unit for imaging data collected at all six MIRECC main sites. This group will focus on measuring the structure and function of the hippocampus, a region of the brain involved in memory function. Damage to this structure, as measured by neuroimaging, may be important in understanding the basic mechanisms of both PTSD and dementias as well as having potential to predict the responsiveness of certain medications and behavioral treatments that may require an intact hippocampus to work properly. This section is unique insofar as it will provide technology to collect imaging data in six remote sites, several with different equipment, yet allow processing of the raw data centrally and examine the same structures using the same quantification techniques. Such central processing of imaging data will likely lead to cost-effective ways to process images, since much of the expensive development of processing techniques and quantification need only be carried out at one site.

The Neurochemistry Core is led by Dr. Frank Longo of VAMC San Francisco and University of California at San Francisco in collaboration with Dr. Greer Murphy of Stanford University. This Core will provide a centralized processing unit and bank for genetic data collected at all six MIRECC main sites. This group will focus on genetic markers likely to be associated with reduced responsiveness to medications as well as other genetic markers likely to be associated with adverse drug reactions. These studies will be conducted in veterans with a range of ethnic backgrounds. Many veterans with particular genetic profiles on specific genes are more subject to serious side-effects of medications than are patients without these genetic variations. This work will look into the usefulness of such genetic typing as a method to flag patient charts to warn treating physicians that an individual may have a genetic trait that makes that particular patient more susceptible to medication side-effects.

Finally, the Chronobiology and Sleep Core is led by Drs. Kate Benson and Vincent Zarcone of VAPAHCS and Stanford University as well as Dr. Thomas Neylan of VAMC San Francisco and University of California at San Francisco. This Core will provide a centralized processing unit for actigraphic data collected at all six MIRECC main sites. The actigraph is a "field robust" wrist-watch-size motion detector that provides a cost-effective way to collect sleep and chronobiological data in the patient’s home. As in the case of the centrallized processing of neuroimaging data, these sleep researchers will evaluate the usefullness of central processing of field-robust sleep measures to attempt to bring sleep assessments to clinics not associated with sleep centers.

Director of Educational Activities will be Fred Gusman and of VA Health Care System Palo Alto. He will work with Dr. Joe Ruzek, who will focus on PTSD educational activities, and Dr. Dolores Gallagher, who will focus on dementia educational activities. Our education plan is designed to disseminate current state-of-the-art knowledge as well as new information yielded from MIRECC research investigations specific to the care of veterans with PTSD and dementia.

In the next six months we will assess the needs of health care providers, researchers, and trainees across the VISN to develop programs that are based on clinical needs. Thus, our programs will have targeted utility for health care providers in the field.

In addition, in the next year in collaboration with industry based in "Silicon Valley" we will establish a novel video-streaming infrastructure across the Sierra-Pacific Network to allow state-of-the art educational activities to be viewed on personal computers (PCs) in all VA facilities, from large tertiary care centers to small local clinics. We have already begun coordination of our educational plans with relevant information processing experts at targeted sites across the Sierra-Pacific Network.

Finally, the Methodology and Evaluation Core is led by Drs. Rudolf Moos,

John Finney, Paul Barnett, John Brooks, and Helena Kraemer of VAPAHCS and Stanford. In addition to providing consultation on methodological issues, the primary function of this Core will be to evaluate how well the Sierra Pacific MIRECC meets its goals of improving the mental health care of veterans in our VISN.