PERSPECTIVE: Economic and Policy Research Interests Highlighted in the 25th NIMH-Sponsored Mental Health Services Research Conference.

BACKGROUND: The National Institute of Mental Health (NIMH) remains committed to addressing real-world challenges with delivering high quality mental health care to people in need by advancing a services research agenda to improve access, continuity, quality, equity, and value of mental healthcare nationwide, and to improve outcomes for people with serious mental illnesses (SMI). The NIMH-Sponsored Mental Health Services Research Conference (MHSR) is a highly productive venue for discussing topics of interest to NIMH audiences and disseminating NIMH's latest research findings directly to mental health clinicians, policy makers, administrators, advocates, consumers, and scientists who attend. AIMS: This Perspective summarizes and provides highlights from the 25th MHSR. It also reviews three papers presented at the 25th MSHR and subsequently published in the June 2023 special issue of The Journal of Mental Health Policy and Economics (JMHPE). METHODS: The authors review three papers published in the June 2023 special issue of JMHPE, identifying common themes across the papers and illustrating how the papers' findings promote key areas of NIMH research interests. RESULTS: Three important areas are highlighted in this review: (i) service user engagement in the research enterprise, (ii) financing the implementation of the 988 Suicide and Crisis Lifeline, and (iii) methods to predict mental health workforce turnover. DISCUSSION: These three papers illustrate key areas in which policy research can help to promote quality mental health care. One notable common theme across the papers is that of the role that end users play in the research enterprise. The papers focus on (i) service users and the value they bring to informing the practice of research, (ii) policy makers and the information they need to make evidence-informed decisions, and (iii) provider organization leadership, by using an innovative machine learning process to help organizations predict and address staff turnover. IMPLICATIONS FOR HEALTH CARE: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. The three papers reviewed in this perspective are exemplars of how necessary stakeholder partnerships are to improve care for those with mental illness. IMPLICATIONS FOR HEALTH POLICIES: The highlighted papers (i) provide recommendations for structural changes to research institutions to increase service user engagement in all aspects of the research enterprise, (ii) identify policy solutions to improve fiscal readiness to address increased demand of 988, and (iii) pilot a novel data-driven approach to predict mental health workforce turnover, a significant problem in community mental health clinics, offering health system leaders and policy makers an opportunity to proactively intervene to help maintain continuity of staffing. IMPLICATIONS FOR FURTHER RESEARCH: Consistent with NIMH's Strategic Plan for Research and current funding announcements, there remains an urgent need to (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services, particularly in historically underserved communities, and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.ing and clinical outcomes remains uncertain.

Twelve-Month Health Care Use and Mortality in Commercially Insured Young People With Incident Psychosis in the United States.

Objective: To assess 12-month mortality and patterns of outpatient and inpatient treatment among young people experiencing an incident episode of psychosis in the United States. Method: Prospective observational analysis of a population-based cohort of commercially insured individuals aged 16-30 receiving a first observed (index) diagnosis of psychosis in 2008-2009. Data come from the US Department of Health and Human Services' Multi-Payer Claims Database Pilot. Outcomes are all-cause mortality identified via the Social Security Administration's full Death Master File; and inpatient, outpatient, and psychopharmacologic treatment based on health insurance claims data. Outcomes are assessed for the year after the index diagnosis. Results: Twelve-month mortality after the index psychosis diagnosis was 1968 per 100000 under our most conservative assumptions, some 24 times greater than in the general US population aged 16-30; and up to 7372 per 100000, some 89 times the corresponding general population rate. In the year after index, 61% of the cohort filled no antipsychotic prescriptions and 41% received no individual psychotherapy. Nearly two-thirds (62%) of the cohort had at least one hospitalization and/or one emergency department visit during the initial year of care. Conclusions: The hugely elevated mortality observed here underscores that young people experiencing psychosis warrant intensive clinical attention-yet we found low rates of pharmacotherapy and limited use of psychosocial treatment. These patterns reinforce the importance of providing coordinated, proactive treatment for young people with psychosis in US community settings.

Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program.

OBJECTIVE: The primary aim of this study was to compare the impact of NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis designed for implementation in the U.S. health care system, with community care on quality of life. METHOD: Thirty-four clinics in 21 states were randomly assigned to NAVIGATE or community care. Diagnosis, duration of untreated psychosis, and clinical outcomes were assessed via live, two-way video by remote, centralized raters masked to study design and treatment. Participants (mean age, 23) with schizophrenia and related disorders and ≤6 months of antipsychotic treatment (N=404) were enrolled and followed for ≥2 years. The primary outcome was the total score of the Heinrichs-Carpenter Quality of Life Scale, a measure that includes sense of purpose, motivation, emotional and social interactions, role functioning, and engagement in regular activities. RESULTS: The 223 recipients of NAVIGATE remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with 181 participants in community care. The median duration of untreated psychosis was 74 weeks. NAVIGATE participants with duration of untreated psychosis of <74 weeks had greater improvement in quality of life and psychopathology compared with those with longer duration of untreated psychosis and those in community care. Rates of hospitalization were relatively low compared with other first-episode psychosis clinical trials and did not differ between groups. CONCLUSIONS: Comprehensive care for first-episode psychosis can be implemented in U.S. community clinics and improves functional and clinical outcomes. Effects are more pronounced for those with shorter duration of untreated psychosis.

Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness: A Comprehensive Review.

People with serious mental illness (SMI) have mortality rates 2 to 3 times higher than the overall US population, largely due to cardiovascular disease. The prevalence of cardiovascular risk factors such as obesity and diabetes mellitus and other conditions, such as HIV/AIDS, is heightened in this group. Based on the recommendations of a National Institute of Mental Health stakeholder meeting, we conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. Peer-reviewed studies were identified using 4 major research databases. Randomized controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included. Information was abstracted from each study by 2 trained reviewers, who also rated study quality using a standard tool. Following individual study review, the quality of the evidence (high, medium, low) and the effectiveness of various interventions were synthesized. 108 studies were included. The majority of studies examined interventions to address overweight/obesity (n = 80). The strength of the evidence was high for 4 interventions: metformin and behavioral interventions had beneficial effects on weight loss; and bupropion and varenicline reduced tobacco smoking. The strength of the evidence was low for most other interventions reviewed. Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors. In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.

Quality of medical care for persons with serious mental illness: A comprehensive review.

OBJECTIVES: Prior studies suggest variation in the quality of medical care for somatic conditions such as cardiovascular disease and diabetes provided to persons with SMI, but to date no comprehensive review of the literature has been conducted. The goals of this review were to summarize the prior research on quality of medical care for the United States population with SMI; identify potential sources of variation in quality of care; and identify priorities for future research. METHODS: Peer-reviewed studies were identified by searching four major research databases and subsequent reference searches of retrieved articles. All studies assessing quality of care for cardiovascular disease, diabetes, dyslipidemia, and HIV/AIDs among persons with schizophrenia and bipolar disorder published between January 2000 and December 2013 were included. Quality indicators and information about the study population and setting were abstracted by two trained reviewers. RESULTS: Quality of medical care in the population with SMI varied by study population, time period, and setting. Rates of guideline-concordant care tended to be higher among veterans and lower among Medicaid beneficiaries. In many study samples with SMI, rates of guideline adherence were considerably lower than estimated rates for the overall US population. CONCLUSIONS: Future research should identify and address modifiable provider, insurer, and delivery system factors that contribute to poor quality of medical care among persons with SMI and examine whether adherence to clinical guidelines leads to improved health and disability outcomes in this vulnerable group.

Effects of mental health benefits legislation: a community guide systematic review.

CONTEXT: Health insurance benefits for mental health services typically have paid less than benefits for physical health services, resulting in potential underutilization or financial burden for people with mental health conditions. Mental health benefits legislation was introduced to improve financial protection (i.e., decrease financial burden) and to increase access to, and use of, mental health services. This systematic review was conducted to determine the effectiveness of mental health benefits legislation, including executive orders, in improving mental health. EVIDENCE ACQUISITION: Methods developed for the Guide to Community Preventive Services were used to identify, evaluate, and analyze available evidence. The evidence included studies published or reported from 1965 to March 2011 with at least one of the following outcomes: access to care, financial protection, appropriate utilization, quality of care, diagnosis of mental illness, morbidity and mortality, and quality of life. Analyses were conducted in 2012. EVIDENCE SYNTHESIS: Thirty eligible studies were identified in 37 papers. Implementation of mental health benefits legislation was associated with financial protection (decreased out-of-pocket costs) and appropriate utilization of services. Among studies examining the impact of legislation strength, most found larger positive effects for comprehensive parity legislation or policies than for less-comprehensive ones. Few studies assessed other mental health outcomes. CONCLUSIONS: Evidence indicates that mental health benefits legislation, particularly comprehensive parity legislation, is effective in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. Evidence was limited for other mental health outcomes.

Screening for cardiovascular risk factors in adults with serious mental illness: a review of the evidence.

BACKGROUND: Adults with serious mental illness have a mortality rate two to three times higher than the overall US population, much of which is due to somatic conditions, especially cardiovascular disease. Given the disproportionately high prevalence of cardiovascular risk factors in the population with SMI, screening for these conditions is an important first step for timely diagnosis and appropriate treatment. This comprehensive literature review summarizes screening rates for cardiovascular risk factors in the population with serious mental illness. METHODS: Relevant articles published between 2000 and 2013 were identified using the EMBASE, PsychInfo, PubMed, SCOPUS and Web of Science databases. We reviewed 10 studies measuring screening rates for obesity, diabetes, dyslipidemia, and hypertension in the population with serious mental illness. Two reviewers independently extracted information on screening rates, study population, and study setting. RESULTS: Rates of screening varied considerably by time period, study population, and data source for all medical conditions. For example, rates of lipid testing for antipsychotic users ranged from 6% to 85%. For some conditions, rates of screening were consistently high. For example, screening rates for hypertension ranged from 79% - 88%. CONCLUSIONS: There is considerable variation in screening of cardiovascular risk factors in the population with serious mental illness, with significant need for improvement in some study populations and settings. Implementation of standard screening protocols triggered by diagnosis of serious mental illness or antipsychotic use may be promising avenues for ensuring timely diagnosis and treatment of cardiovascular risk factors in this population.

Review of the evidence: prevalence of medical conditions in the United States population with serious mental illness.

OBJECTIVE: Persons with serious mental illness (SMI) have high rates of premature mortality from preventable medical conditions, but this group is underrepresented in epidemiologic surveys and we lack national estimates of the prevalence of conditions such as obesity and diabetes in this group. We performed a comprehensive review to synthesize estimates of the prevalence of 15 medical conditions among the population with SMI. METHOD: We reviewed studies published in the peer-reviewed literature from January 2000 to August 2012. Studies were included if they assessed prevalence in a sample of 100 or more United States (US) adults with schizophrenia or bipolar disorder. RESULTS: A total of 57 studies were included in the review. For most medical conditions, the prevalence estimates varied considerably. For example, estimates of obesity prevalence ranged from 26% to 55%. This variation appeared to be due to differences in measurement (e.g., self-report versus clinical measures) and underlying differences in study populations. Few studies assessed prevalence in representative, community samples of persons with SMI. CONCLUSIONS: In many studies, the prevalence of medical conditions among the population with SMI was higher than among the overall US population. Screening for and monitoring of these conditions should be common practice in clinical settings serving persons with SMI.

Prescription practices in the treatment of first-episode schizophrenia spectrum disorders: data from the national RAISE-ETP study.

OBJECTIVE: Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients. METHOD: Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project's Early Treatment Program (RAISE-ETP), a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry. RESULTS: The authors identified 159 patients (39.4% of the sample) who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for olanzapine (often at high dosages), 23.3% for more than one antipsychotic, 36.5% for an antipsychotic and also an antidepressant without a clear indication, 10.1% for psychotropic medications without an antipsychotic, and 1.2% for stimulants. Multivariate analysis showed evidence for sex, age, and insurance status effects on prescription practices. Racial and ethnic effects consistent with effects reported in previous studies of multiepisode patients were found in univariate analyses. Despite some regional variations in prescription practices, no region consistently had different practices from the others. Diagnosis had limited and inconsistent effects. CONCLUSIONS: Besides prescriber education, policy makers may need to consider not only patient factors but also service delivery factors in efforts to improve prescription practices for first-episode schizophrenia patients.

Duration of Untreated Psychosis in Community Treatment Settings in the United States.

OBJECTIVE: This study is the first to examine duration of untreated psychosis (DUP) among persons receiving care in community mental health centers in the United States. METHODS: Participants were 404 individuals (ages 15-40) who presented for treatment for first-episode psychosis at 34 nonacademic clinics in 21 states. DUP and individual- and site-level variables were measured. RESULTS: Median DUP was 74 weeks (mean=193.5±262.2 weeks; 68% of participants had DUP of greater than six months). Correlates of longer DUP included earlier age at first psychotic symptoms, substance use disorder, positive and general symptom severity, poorer functioning, and referral from outpatient treatment settings. CONCLUSIONS: This study reported longer DUP than studies conducted in academic settings but found similar correlates of DUP. Reducing DUP in the United States will require examination of factors in treatment delay in local service settings and targeted strategies for closing gaps in pathways to specialty FEP care.

Cardiometabolic risk in patients with first-episode schizophrenia spectrum disorders: baseline results from the RAISE-ETP study.

IMPORTANCE: The fact that individuals with schizophrenia have high cardiovascular morbidity and mortality is well established. However, risk status and moderators or mediators in the earliest stages of illness are less clear. OBJECTIVE: To assess cardiometabolic risk in first-episode schizophrenia spectrum disorders (FES) and its relationship to illness duration, antipsychotic treatment duration and type, sex, and race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS: Baseline results of the Recovery After an Initial Schizophrenia Episode (RAISE) study, collected between July 22, 2010, and July 5, 2012, from 34 community mental health facilities without major research, teaching, or clinical FES programs. Patients were aged 15 to 40 years, had research-confirmed diagnoses of FES, and had less than 6 months of lifetime antipsychotic treatment. EXPOSURE: Prebaseline antipsychotic treatment was based on the community clinician's and/or patient's decision. MAIN OUTCOMES AND MEASURES: Body composition and fasting lipid, glucose, and insulin parameters. RESULTS: In 394 of 404 patients with cardiometabolic data (mean [SD] age, 23.6 [5.0] years; mean [SD] lifetime antipsychotic treatment, 47.3 [46.1] days), 48.3% were obese or overweight, 50.8% smoked, 56.5% had dyslipidemia, 39.9% had prehypertension, 10.0% had hypertension, and 13.2% had metabolic syndrome. Prediabetes (glucose based, 4.0%; hemoglobin A1c based, 15.4%) and diabetes (glucose based, 3.0%; hemoglobin A1c based, 2.9%) were less frequent. Total psychiatric illness duration correlated significantly with higher body mass index, fat mass, fat percentage, and waist circumference (all P<.01) but not elevated metabolic parameters (except triglycerides to HDL-C ratio [P=.04]). Conversely, antipsychotic treatment duration correlated significantly with higher non-HDL-C, triglycerides, and triglycerides to HDL-C ratio and lower HDL-C and systolic blood pressure (all P≤.01). In multivariable analyses, olanzapine was significantly associated with higher triglycerides, insulin, and insulin resistance, whereas quetiapine fumarate was associated with significantly higher triglycerides to HDL-C ratio (all P≤.02). CONCLUSIONS AND RELEVANCE: In patients with FES, cardiometabolic risk factors and abnormalities are present early in the illness and likely related to the underlying illness, unhealthy lifestyle, and antipsychotic medications, which interact with each other. Prevention of and early interventions for psychiatric illness and treatment with lower-risk agents, routine antipsychotic adverse effect monitoring, and smoking cessation interventions are needed from the earliest illness phases.

Integrated care: High-impact mental health-primary care research for patients with multiple comorbidities.

Patients with multiple psychiatric and medical comorbidities are common in primary care practices (PCPs), and recent health care reforms will likely lead to an increase in their numbers. PCPs need flexible, integrated mental health-primary care interventions that are applicable to these complex patients and compatible with the PCP setting. Generating practice-ready solutions for rapid uptake in typical PCPs requires a new direction for mental health-primary care research. This column describes an approach that embraces both real-world relevance and methodological rigor to stimulate such research. The approach emphasizes generating knowledge that decision makers need, using practice-based evidence and efficient methods, and planning for sustainability and broad uptake from the outset.

Research and services partnerships: partnership: a fundamental component of dissemination and implementation research.

This column describes the essential role of partnerships in the conduct of dissemination and implementation (D&I) research. This research field, which develops knowledge to support the integration of health information and evidence-based practices, has thrived in recent years through research initiatives by federal agencies, states, foundations, and other funders. The authors describe three ongoing studies anchored in research partnerships to improve the implementation of effective practices within various service systems. Inherent in the challenge of introducing evidence-based practices in clinical and community settings is the participation of a wide range of stakeholders who may influence D&I efforts. Opportunities to enhance partnerships in D&I research are described, specifically in light of recent initiatives led by the National Institutes of Health. Partnerships remain a crucial component of successful D&I research. The future of the field depends on the ability to utilize partnerships to conduct more rigorous and robust research.

The mental health treatment study.

Security Disability Insurance (SSDI) beneficiaries with primary psychiatric impairments comprise the largest, fastest growing, and most costly population in the SSDI program. The Mental Health Treatment Study provides a comprehensive test of the hypothesis that access to evidence-based employment services and behavioral health treatments, along with insurance coverage, can enable SSDI beneficiaries with psychiatric impairments to return to competitive employment. It will also examine which beneficiaries choose to enter an employment study under such conditions. Currently in the field in 22 cities across the U.S., the MHTS aims to recruit 3,000 SSDI beneficiaries with psychiatric impairments into a randomized controlled trial. This paper describes the MHTS, its background, and its process and outcome assessments.

Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program.

OBJECTIVE: The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries' financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children. METHODS: Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending. RESULTS: The apparent increase in the rate of children's mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children's mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant. CONCLUSIONS: Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.

Behavioral health insurance parity for federal employees.

BACKGROUND: To improve insurance coverage of mental health and substance-abuse services, the Federal Employees Health Benefits (FEHB) Program offered mental health and substance-abuse benefits on a par with general medical benefits beginning in January 2001. The plans were encouraged to manage care. METHODS: We compared seven FEHB plans from 1999 through 2002 with a matched set of health plans that did not have benefits on a par with mental health and substance-abuse benefits (parity of mental health and substance-abuse benefits). Using a difference-in-differences analysis, we compared the claims patterns of matched pairs of FEHB and control plans by examining the rate of use, total spending, and out-of-pocket spending among users of mental health and substance-abuse services. RESULTS: The difference-in-differences analysis indicated that the observed increase in the rate of use of mental health and substance-abuse services after the implementation of the parity policy was due almost entirely to a general trend in increased use that was observed in comparison health plans as well as FEHB plans. The implementation of parity was associated with a statistically significant increase in use in one plan (+0.78 percent, P<0.05) a significant decrease in use in one plan (-0.96 percent, P<0.05), and no significant difference in use in the other five plans (range, -0.38 percent to +0.23 percent; P>0.05 for each comparison). For beneficiaries who used mental health and substance-abuse services, spending attributable to the implementation of parity decreased significantly for three plans (range, -201.99 dollars to -68.97 dollars; P<0.05 for each comparison) and did not change significantly for four plans (range, -42.13 dollars to +27.11 dollars; P>0.05 for each comparison). The implementation of parity was associated with significant reductions in out-of-pocket spending in five of seven plans. CONCLUSIONS: When coupled with management of care, implementation of parity in insurance benefits for behavioral health care can improve insurance protection without increasing total costs.

Public policy and evidence-based practice.

The time has come to add to the body of EBP implementation knowledge at multiple levels, including knowledge about policy, program priorities, clinician practice, consumer adherence, and family member support. Implementation at the policy level, however, is primary and paramount. The national initiative supporting EBP implementation is one of the most important innovations on the mental health horizon. It will serve as the testing ground for what can be learned about bridging the gap between science and service. This important initiative will not go far if it is not supported by mental health policies--at state and federal levels--that create the organizational and financial incentives to implement EBPs. In addition, it will be a time-limited activity if it also does not yield lessons about how to adapt to new evidence and on-going systemic changes. Organizations must be flexible and able to learn and adapt. The promise of decades of research must be realized in practice. There is an opportunity to combine quality improvement with accountability through performance measurement and the implementation of effective new services and treatments. The Surgeon General simultaneously identified this research's promise and documented its shortcomings. His report outlines courses of action for policymakers that should guide clinicians away from service disparities and toward the implementation of EBP.