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Goal 4: Strengthen the Public Health Impact of NIMH-Supported Research

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Through mental health services research, investigators seek generalizable strategies for increasing access to evidence-based interventions, fostering high quality care, and improving clinical and recovery outcomes for millions of people with mental illnesses. To increase the public health impact of services studies, investigators test ways to adapt, implement, and scale-up effective interventions for varied populations across multiple service settings in a cost-effective manner. This work requires new research designs, measures, and statistical approaches for evaluating system-wide interventions and measuring population-level effects, and may benefit from stakeholder input. New models of healthcare financing and delivery of care, along with evolving technologies such as electronic medical records, health informatic systems, and multipurpose mobile computing devices, present unique opportunities for conducting deployment-focused services research in real-world settings. Such research may help to improve mental health care by optimizing the organization and sustained delivery of evidence-based prevention and treatment intervention, speeding the implementation of research-informed innovations in community settings, and ultimately ensuring optimal outcomes for all affected individuals, including those from underrepresented and underserved communities.

The following Objectives further define this Goal:

Practice-based research, conducted within primary and specialty healthcare settings, is uniquely suited to address questions concerning clinical epidemiology, access to care, quality and continuity of services, and clinical and societal outcomes associated with mental health interventions. Weaving systematic data collection into routine care is an efficient means for capturing information about clinical populations, system-level performance, and outcomes for key subgroups. In addition, NIMH recognizes a need for more research on the impact of various financing strategies to ensure care for all, especially children and adolescents with developmental precursors of mental illnesses and people with serious mental illnesses and complex health needs.

To test approaches for improving the efficiency, effectiveness, and reach of mental health services, NIMH will support research that employs the following Strategies:

Interest areas include:

  1. Examining mental illness prevalence, service use, treatment response, and relapse events, via data from large, diverse, and representative population samples or practice-based research networks, to identify new opportunities for individual or system-level interventions.
  2. Promoting data-driven approaches for improving screening and detection of low base-rate events (e.g., suicidal behavior, first episode psychosis); monitoring real-time trends in incidence, prevalence, and severity; and identifying novel targets for preventive interventions.

Interest areas include:

  1. Developing pragmatic, valid, and reliable measures of engagement, intervention fidelity and quality, and outcomes that can be applied at the person, clinic, system, and/or population level to advance measurement-based care.
  2. Comparing performance feedback methods and quality improvement processes for adoption across a range of systems and age groups to advance the principles of learning healthcare.
  3. Applying computational modeling and data analytics to electronic health records, administrative claims data, and information from other sources to study mental health needs and services over time, and to identify mutable targets for improving service access, delivery, and outcomes.

Interest areas include:

  1. Comparing alternative financing mechanisms that promote high quality, clinically effective, and efficient mental health care across settings and populations and discourage low-value services.
  2. Optimizing public and commercial financing mechanisms that cover integrated care packages for individuals with complex needs (e.g., combination psychopharmacology, psychotherapy, rehabilitative therapy, care coordination interventions).
  3. Studying the impact of national, state, provincial, or other healthcare system rules and regulations on participation in provider reimbursement and/or waiver programs.

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The delay between research and practice is often lengthy, and delayed uptake of effective mental health interventions is widespread. NIMH recognizes the need for research to develop and test strategies that speed dissemination, adoption, and implementation of evidence-based interventions and sustain these practices over time. Strategies that reduce the lag between research discovery and science-driven practice could radically alter the quality and outcomes of care provided for all individuals with mental health conditions.

To accelerate deployment-focused intervention and services research, NIMH encourages partnerships between scientists, those who directly benefit from evidence-based approaches (e.g., service users, caregivers), and public and private stakeholders who oversee the provision and financing of care. Effective partnerships among these stakeholders are crucial for identifying salient services research questions, developing realistic interventions, and testing adoptable, scalable, and sustainable approaches that promote continuously improving mental health care.

To strengthen research-practice partnerships that speed adoption, implementation, and continuous improvement of evidence-based mental health services, NIMH will support studies that employ the following Strategies:

Interest areas include:

  1. Conducting dissemination and implementation studies that reflect active partnerships between scientists and key stakeholders across all phases of the research process.
  2. Investigating strategies that promote rapid incorporation of practice-based research findings into clinical practice guidelines as well as reimbursement policies for mental health services.
  3. Addressing workforce issues related to implementation of evidence-based approaches (e.g., training providers in new treatment models and technologies, maintaining provider competence, involving paraprofessionals and peer providers, retaining qualified providers, managing staff turnover without compromising the quality of services).

Interest areas include:

  1. Examining and monitoring client, caregiver, provider, and organizational-level factors that affect the transportability of interventions (i.e., the degree to which the evidence-informed intervention can be implemented with fidelity).
  2. Adapting interventions and services with demonstrated effectiveness in one setting to determine fit for use in other contexts such as non-specialty community/practice settings where mental health care is delivered (e.g., primary care, schools, child and adult welfare, criminal and juvenile justice settings, long-term care facilities, geriatric service programs).

Interest areas include:

  1. Developing and validating novel tools, smart technologies, and ecologically valid measures to monitor the engagement of intervention targets in services interventions.
  2. Examining and adapting the attributes of evidence-based interventions (e.g., intensity, duration, frequency) that affect their generalizability to practice settings.
  3. Developing and testing decision-support algorithms for matching services within a health system (e.g., pharmacotherapy, psychotherapy, rehabilitation, care coordination) to client’s needs over time, including stepped-care algorithms that span non-specialty and mental health specialty services.

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Service delivery models provide a framework for mental health care, which account for various settings, providers, and resources. Available data indicate that many service delivery models are inadequate to meet the mental health service needs in the United States and around the globe. To provide high quality care to populations in need, researchers may need to adapt evidence-based models to account for moderators known to impact intervention effectiveness in subgroups. Services research that tests adaptations should be designed to test whether the adapted strategy counteracts moderators that have been shown to impede effectiveness and clinical outcomes.

NIMH is committed to supporting research that reduces disparities and advances equity in mental health services and outcomes. As such, we need innovative and sustainable service delivery models that address disparities that stem from historical, social, and economic inequities that disproportionately affect marginalized populations and people with serious mental illnesses, to include people experiencing instability in housing, income, and food. People with serious mental illness are among the first and most disproportionately affected by these social and economic insecurities. We must develop and test novel components of care across multiple settings where mental health services are needed and use developmentally and culturally appropriate tools to better reach populations in need and substantially improve the delivery of evidence-based mental health care.

To improve the outcomes of individuals receiving mental health services and to ensure equity of outcomes in all populations, NIMH will support research to develop innovative services delivery models that employs the following Strategies:

Interest areas include:

  1. Testing innovative approaches for reducing empirically documented disparities in care access, quality, and outcomes for racial and ethnic minority groups, individuals limited by language or cultural barriers, sexual and gender minorities, individuals living in rural areas, socioeconomically disadvantaged persons, and other underserved groups.
  2. Combining data from multiple sources of information (e.g., electronic health records, administrative claims data, epidemiologic surveys, census data) to identify underserved groups and to explore novel approaches for coordinating health/community service resources and improving overall health outcomes.
  3. Conducting research to better understand, predict, and reduce mental health workforce shortages across pediatric, adolescent, adult, and geriatric services.

Interest areas include:

  1. Developing and testing innovative strategies to promote early identification and engagement in prevention and mental health services for children, adolescents, and adults, especially for those experiencing early symptoms of mental illness.
  2. Characterizing care pathways to identify mutable barriers and facilitators to improving access to care across the lifespan, including children at risk for autism or mental illness, transition-age youth with autism or emerging mental illnesses, and adults with autism or mental illness conditions.
  3. Defining and testing the specific mechanism(s) of action (i.e., targets) in service delivery approaches purported to improve mental health outcomes across developmental stages. When paraprofessionals or peer providers are delivering services, the research should make clear the intended purpose for involving nontraditional staff (e.g., addressing work force shortages, instilling hope and re-moralization, improving client engagement) and then test whether engagement of these targets mediates outcomes, with consideration for scalability of strategies that prove effective.

Interest areas include:

  1. Using technology to improve early detection of mental illnesses, connect clients across all ages to evidence-based care, and increase reach of and engagement with services for underserved populations, and improve client-level outcomes.
  2. Developing and testing clinician-facing “dashboards” or other system-level technologies that can be used to support providers in their use of measurement-based care, to facilitate system-level quality monitoring and improvement, and to improve clinical workflows.
  3. Developing and testing implementation strategies for evidence-based practices (e.g., ensuring availability, accessibility, effectiveness, scalability) in non-specialty settings where significant unmet need exists (e.g., the criminal justice system, military or veteran organizations, and the child welfare system).
  4. Building novel service delivery models that capitalize on systems that are already engaging individuals with mental health needs (e.g., schools, social services, or other community-based settings, online/virtual communities).

Interest areas include:

  1. Developing and testing service delivery models for comorbid conditions, such as care decision models that integrate treatment for mental illness and medical conditions.
  2. Developing and validating decision support tools to assess mental health needs, medical risk factors, and mental health/medical treatment availability in non-specialty settings where children and adolescents are served, and to assist with treatment planning.
  3. Using existing and developing novel technologies (e.g., mobile devices, information systems) to significantly improve access, engagement, quality, effectiveness and efficiency of integrated mental health services.
  4. Investigating strategies for active symptom management that reduce the symptom burden in individuals with serious mental illnesses and multiple chronic conditions.

Progress for Goal 4

Bringing knowledge to practice, improvements to services, and better outcomes to individuals.