Improving Mental Health Care and Outcomes: NIMH Services Research

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Improving Mental Health Care and Outcomes NIMH
Services Research

• Junius Gonzales, MD
• Chief, Services Research Clinical Epidemiology
  Branch
• National Institute of Mental Health, NIH

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Presentation Outline

• Introduction
• Services Research Today Science, Capacity
  Building and Results
• NIMH Services Research 2003-2006
• The MissionScientific Rigor Relevance in
  Real Time
• The Foci and the Plans

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The Challenge

• What we really want to get at is not how many
  reports have been done, but how many people's
  lives are being bettered by what has been
  accomplished. In other words, is it being used,
  is it being followed, is it actually being given
  to patients?What effect is it having on
  people?
• Congressman John Porter, 1998
• Chairman, House Appropriations Subcommittee on
• Labor, HHS, and Education

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Mental Health Services Research Recent
Contributions

• SPMI Assertive Community Treatment strong
  evidence (60 trials), Medicaid but how and why?
• Methodologies and approaches
• mixed models www.dsi-software.com/mixor.html
• qualitative methods and behavioral science
  theories to bear on understanding moderators and
  mediators of treatment effectiveness
• heightened stats/methods capacity in the field

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Recent Contributions

• Financing Research on Parity
• 60 NIMH studies contributed to parity reports
• Primary Care Research several cost-effective
  interventions for depression
• Sociocultural
• 2 highly successful centers -- Latinos Native
  Americans

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SRCEB FY 00-present TheBridging Platform

• NIMH research must be useful and practical for
  people with mental illnesses, clinicians,
  purchasers, and policymakers NIMH should
  consider the domains of efficacy, effectiveness,
  practice and service systems research to foster
  integration across fields expedite
  implementation
• 10 programs centers training grants
• Nearly 280 grants 90,000,000
• gt55 increase in applications from 2001--gt2002

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Breadth of NIMH Services Research

• Child Adolescent
• Primary Care
• Quality of Care Outcomes
• Financing Managed Care
• Systems Research

• Sociocultural
• Research Methods
• Clinical Epidemiology
• Dissemination Research
• Disparities
• Disablement Functioning

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SRCEB Vision Scientific Rigor and Relevance in
Real Time

• Scientific Issues
• ecological rationality and validity making a
  contribution to theory
• balancing innovation and rigor translating behav
  sciences
• informed new QOC and DI Program Announcements
• Workshops and conferences ( Beyond the Clinic
  Walls -- Triple Institute effort)
• Capacity Issues
• Mechanisms to involve real world settings and
  needs
• IP-RISP, Time Sensitive Mechanisms, Centers,
  exploratory grants
• States RFA to ready them to study barriers and
  facilitators of implementing EBP (partnered with
  CMHS)
• Partnerships AHRQ, CMS, SAMHSA, other

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The Gap Problem

• Gaps
• between research and practice
• between research and policy
• Estimates
• over 15 years to move findings into daily
  clinical practice
• variations in psychotropic prescribing
• latest JAMA article (Kessler et al) on minimal
  QOC
• Part, but not all, of the solution
• advancing the science of dissemination
  implementation

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Science to Services Initiative

• Why?
• The need for improved mental health and substance
  services delivery
• What?
• A synergistic collaboration between NIH and
  SAMHSA to build on specific initiatives and
  activate new endeavors
• How?
• NIMH-NIDA-NIAAA/SAMHSA Centers Work Group
• Dyadic Committees (NIMH-CMHS) strategic
• Topical Project Teams tactical

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State Implementation of EBPs NIMH CMHS RFA

• Purpose
• provide states with one year planning grants
• to identify factors that may impede or facilitate
  implementation
• The Process
• Technical Assistance Workshop 60 participants in
  September, 2002
• 37 Applications submitted October 1, 2002 from
  31 states, Puerto Rico
• March 2003 Review
• PHASE II RFA Forthcoming

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Capacity Building Mechanisms

• Interventions Practice Research Infrastructure
  Support Program (R24)
• 5 years for partnerships b/t researchers and real
  world settings with little or no research
• 400,000/yr direct costs
• Field Collaborative for Traumatized Children
• Implementing Treatment Algorithms in Criminal
  Justice Settings

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Capacity Building Mechanisms

• Time Sensitive Opportunities
• real world, real time, one time unique
  opportunity
• expedited submission, review, funding
• can be small, exploratory or regular grant
• PA 01-136

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The Two Directions

• Dissemination and Implementation Research
• 3 Major Issues Reflecting Tensions of Rigor,
  Relevance and Real-time for Clinicians
• 1. What evidence ensures whether an
  evidence-based practice is appropriate for a
  given care setting?
• 2. Does a care setting have capacity to
  implement EBP?
• 3. Do our researchers have the knowledge/skills
  necessary to conduct D and I Studies?
• PA 02-131

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Disablement and Reintegration

• Scientific Challenges
• The single greatest challenge is to move
  researchers who are used to program evaluation to
  also advance science by incorporating new methods
  and perspectives
• Developing a way to measure functioning that is
  meaningful to consumers with different life
  circumstances and needs and useful for
  researchers and policy makers.
• Integrating the methods and insights of
  neuroscience, neuropsychology, and the behavioral
  sciences into the services research on
  rehabilitation and consumer community
  reintegration.

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Science to Innovative Service Examples

• Psychosis Early Detection, Intervention
  Prevention (William McFarlane, Maine Medical
  Center)
• Testing EBP and Organization Effects in Rural
  Appalachia (Charles Glisson, University of TN)
• CTI In the Transition from Hospital to Community
  (Dan Herman, NY State Psychiatric Institute)

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Psychosis Early Detection, Intervention
Prevention

• Goal intervene early, prior to onset, in the
  course of the onset of psychotic disorders to
  arrest the development of psychotic symptoms and
  functional disability
• Intervention a specialized combination of
  psychoeducational multifamily group and assertive
  community treatment, with medication, if
  necessary

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Testing EBP and Organization Effects in Rural
Appalachia

• Goal to overcome barriers to the implementation
  of effective mental health treatments for
  disruptive/antisocial youth in very rural, deeply
  impoverished communities
• Intervention Multisystemic therapy (MST) an
  organizational-community intervention that
  changes the social context in which the service
  is provided and supports therapists' efforts to
  serve children in widely-dispersed, isolated
  communities

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http//www.nimh.nih.gov/srceb/index.cfm301-443-6
233Division of Services and Interventions
ResearchNational Institute of Mental
HealthNational Institutes of Health