Highlighting Services and Effectiveness Research at NIMH
NIMH envisions a world in which mental illnesses are prevented and cured.
Our vision statement says it all. We won’t stop our efforts to transform the understanding and treatment of mental illnesses until that vision is realized. To that end, we invest in basic research to understand the mechanisms and origins of mental illnesses, as well as translational research to develop novel treatments and prevention measures based on this understanding. But research doesn’t stop with the discovery of a new treatment. In order to prevent and cure illnesses, these treatments need to actually be tested and put to use in the clinic. Once the effectiveness of an intervention is established, figuring out how best to deliver effective therapies is the domain of services research, a key component of our research portfolio at NIMH that focuses on impacting patients in the near term.
Services research includes figuring out who needs treatment, where they are, where they access treatment, what works best in those settings, and how to keep people engaged in treatment long enough to receive benefit. Services researchers also examine how best to ensure quality—making sure evidence-based treatments are accurately and appropriately delivered; effectiveness—making sure treatments have a positive impact on individuals with mental illnesses seen in community practice settings (a.k.a., the real world); equitability—making sure treatments are accessible and efficacious for all groups of people; and value—making sure the outcomes are worth the investment because in all settings, resources are limited and tradeoffs often need to be made.
Ideally, care can be delivered by a diverse group of practitioners distributed across a diverse range of clinical settings. In all of this work, NIMH research focuses squarely on acute and long-term symptom reduction, remission, and improved community functioning—endpoints that are truly meaningful for individuals and families dealing with mental illness. To accomplish these goals, researchers work directly with individuals and families who are struggling, but also work with providers, decision makers, and healthcare system leaders to effect changes at multiple levels. In this Director’s Message, I thought I would highlight a few notable examples of services and effectiveness research being pursued by NIMH-supported investigators.
Identifying those in need
A key aspect of services research is determining who needs services. I have written in the past about an outstanding example of NIMH-funded research into the identification of suicide risk, the ED-SAFE (Emergency Department Safety Assessment and Follow-up Evaluation) study. The ED-SAFE study showed that universal screening for suicide risk in emergency rooms is an effective way to identify individuals at risk, and that cost-effective interventions in this group can reduce suicide attempts. We have also funded research on big-data approaches to identifying those at risk, with follow-up studies, to determine the effectiveness of interventions, in support of the Zero Suicide campaign.
Big data approaches are helping further define the service needs of individuals with serious mental illness (SMI). For example, a recent study by the NIMH-supported Mental Health Research Network (MHRN) examined health outcomes of individuals under their care as a function of psychiatric diagnosis. The researchers uncovered a startling truth—in the first three years after their diagnosis, individuals experiencing a first episode of psychosis were 7 ½ times more likely to die than someone without psychosis. These data underscore the need for comprehensive, coordinated care for teenagers and young adults with psychosis. Accordingly, NIMH has put forward a series of initiatives to encourage research on strategies for improving the health and longevity of individuals with SMI (see RFA-MH-13-140, RFA-MH-14-060, and RFA-MH-16-600).
Another area in which early identification is crucial is autism. We know that children with autism do better when they get into treatment sooner. NIMH’s ServeASD (Service Research Across the Lifespan for Autism Spectrum Disorder) program supports efforts to develop and study the effectiveness of screening programs aimed at identifying children with autism in the first two years of life. Children enrolled will then be followed into treatment to show definitively that screening improves outcomes by facilitating earlier entry into treatment programs. Other components of the ServeASD program are aimed at the development and testing of interventions and service strategies focused on teenagers and young adults with autism, to determine how best to help them navigate the challenging transition from childhood to adulthood.
Recognizing the importance of early detection and services in general, a current NIMH initiative encourages research focused on developing and testing the effectiveness and implementation of family navigator models designed to promote early access, engagement, and coordination of mental health treatment and services for children and adolescents who are experiencing early symptoms of mental health problems (see PAR-18-428 and PAR-18-429).
Delivering the highest level of care
Effectiveness and services research at NIMH has been deeply informed by the Recovery After Initial Schizophrenia Episode (RAISE) program. The RAISE study demonstrated that coordinated specialty care, involving a team-based approach to medication management, psychotherapy, supports for work and education, and case management improves outcomes for those experiencing a first episode of psychosis. Based on this evidence, Congress provided additional resources to the Substance Abuse and Mental Health Services Administration (SAMHSA) to help start up coordinated specialty care clinics around the country. Working closely together, NIMH and SAMHSA accomplished rapid translation of science to service in first episode psychosis. There are now over 200 clinics offering coordinated specialty care to those with first episode psychosis, and studies have shown the intervention to be cost-effective in addition to being helpful.
Assessing the quality of mental health care is crucial to informing how to effectively implement treatments and improve quality in community settings. Through a recent initiative, several NIMH-supported investigator teams are evaluating a complementary range of innovative approaches to assess the quality of psychotherapy across a variety of target populations. Such efforts include assessing the quality of cognitive behavioral therapy by creating a series of web-based virtual client sessions paired with automated scoring algorithms, or by using mobile technology along with traditional records of treatment sessions to record and rate fidelity to evidence-based practices. Other projects are focused on developing toolkits to make it easier to measure the quality of treatment delivery in child mental health settings: for example, one project seeks to develop a measurement tool for therapist-guided exposure treatment for anxiety disorders among youth.
We remain acutely aware of the fact that even well-delivered therapies only work if they are accessible. NIMH services research includes a number of efforts aimed at understanding when, why, and how mental health services can be challenging to access, with a particular focus on identifying strategies for improving access to effective interventions and services in underserved communities to address health disparities. NIMH-supported research, for example, has shown that one strategy for improving access to effective mental health care is by delivery in integrated care settings, where the individual with a mental health condition can more readily access the treatment she needs. Such access may be especially important for some groups. For example, results of a recent NIMH-funded study showed that brief treatment in pediatric primary care was effective, and Hispanic children and adolescents in particular were much more likely to complete and respond to a mental health treatment delivered in a general pediatric clinic as opposed to when referred to a mental health clinic.
We recognize the tremendous burden imposed by SMI in general and schizophrenia in particular. In order to build on RAISE and other recent successes, NIMH wants to encourage similarly creative and comprehensive studies of the effectiveness of interventions, to achieve rapid implementation of promising interventions, and to enhance the delivery and quality of effective services. To this end, we have begun funding a series of centers focused on research with potential for near-term impact for reducing the burden of SMI. Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness (ALACRITY) Research Centers incorporate new discoveries in basic and clinical research, transformative health care technologies, advances in information science, behavioral economic strategies for influencing health behaviors, and input from stakeholders (e.g., service users, family members, clinicians, payers). The goal is to foster innovative research aimed at increasing the effectiveness of existing interventions, improving delivery and quality of evidence-based services, and accelerating the diffusion, implementation, and continuous improvement of new practices in diverse settings.
These examples underscore the crucial importance of NIMH investments in services and effectiveness research. We remain committed to a robust services and effectiveness portfolio aimed squarely at having a near-term public health impact, recognizing the key role such research plays in achieving our ambitious vision.