Goal 4: Advance Mental Health Services to Strengthen Public Health

Practice-based research, conducted within primary, specialty, and non-traditional health care and other community settings, is uniquely suited to address questions concerning clinical epidemiology; access to care, quality, effectiveness, and continuity of services; and, clinical, functional, 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, provider behavior, system-level performance, and outcomes for key subgroups. NIMH also supports the collection of data that measures social factors that may reduce health disparities and improve health care outcomes. 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 at risk for and with developmental precursors of mental illnesses and people with serious mental illness, neurodevelopmental conditions, 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:

Strategy 4.1. A: Employing assessment platforms within health care and other relevant systems to accurately assess the distribution and determinants of mental illnesses and to inform strategies for improved services 

Interest areas include:

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

Strategy 4.1. B: Optimizing real-world data collection systems to identify strategies for improving access, quality, effectiveness, and continuity of mental health services 

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, community, 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 health care.
3. Applying computational modeling and data analytics to electronic health records, administrative claims data, and information from other sources to study mental health needs, social factors, and services over time, and to identify modifiable targets for improving service access, delivery, quality, and outcomes.

Strategy 4.1. C: Comparing alternative financing models to promote effective and efficient care for adults, older adults, and those with serious mental illness and youth with mental, emotional, and behavioral disorders  

Interest areas include:

1. Comparing alternative financing mechanisms that promote high quality, clinically effective, affordable, 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/county-level, or other health care system rules, regulations, and policies on participation in provider reimbursement and/or waiver programs.
4. Understanding the role of financing and economic factors on developing and supporting a mental health workforce qualified to deliver evidence-based mental health services.
5. Understanding the impact of economic factors affecting patients’ access to and ability to seek high-quality mental health services on mental health outcomes.

The delay between research findings and implementation in real-world settings is often lengthy, and delayed uptake of effective mental health interventions and services 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 illnesses.

To accelerate deployment-focused intervention and services research, NIMH encourages strong partnerships among scientists, those who directly benefit from evidence-based approaches (e.g., service users, providers, caregivers), and other public and private interested parties. Effective partnerships with and among these individuals are crucial for identifying salient services research questions, developing realistic interventions and services, and testing adoptable, scalable, and sustainable approaches that promote continuous improvement of mental health care.

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

Strategy 4.2. A: Strengthening partnerships with key end users and other interested parties to develop and validate strategies for implementing, sustaining, and continuously improving evidence-based practices 

Interest areas include:

1. Conducting dissemination and implementation studies that reflect active partnerships between scientists and key end users and other interested parties, such as service users, providers, and payers, across all phases of the research process.
2. Investigating strategies that promote rapid incorporation of practice-based research findings into health and other system decision making, clinical practice guidelines, and reimbursement and other policies for mental health services.
3. Addressing workforce issues related to implementation and sustainment of evidence-based approaches in health care and other settings (e.g., training providers in new treatment models and technologies; maintaining provider competence; involving paraprofessionals and peer providers in appropriate roles via task-sharing models; retaining qualified providers; managing staff turnover without compromising the quality of services; and, studying policies that impede or facilitate high quality care).

Strategy 4.2. B: Building models to scale-up evidence-based practices for use in public and private primary care, specialty care, and non-traditional settings 

Interest areas include:

1. Examining and monitoring client, caregiver, provider, organizational-level, and community factors, including social factors, that affect the usability and transportability of interventions and services (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 low-resource settings or non-specialty community/practice settings where mental health care is or could be delivered (e.g., primary care, schools, child and adult welfare, criminal and juvenile justice settings, long-term care facilities, geriatric service programs).
3. Employing hybrid effectiveness-implementation designs to enhance the delivery of evidence-based mental health practices and improve implementation outcomes (e.g., fidelity, acceptability, feasibility, appropriateness, penetration, and sustainability of services within a single study).

Strategy 4.2. C: Developing decision-support tools and technologies that increase the effectiveness, implementation, and continuous improvement of mental health interventions in public and private primary care, specialty care, and other settings 

Interest areas include:

1. Developing and validating novel tools, smart technologies, real-time analytics, 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) and implementation (e.g., fidelity, feasibility, acceptability) 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, transition planning) to clients’ needs over time, including stepped-care algorithms that span non-specialty and mental health specialty services.
4. Developing and testing strategies (e.g., shared decision making or behavioral economic approaches to behavior change) to enhance prevention and treatment engagement and adherence.

Service delivery models provide a framework for mental health care, which account for various settings, providers, and resources. Available data indicate that many current service delivery models are inadequate to meet the mental health service needs in the United States. To provide high quality care to groups who are underrepresented in mental health research and have limited access to mental health care, researchers may need to adapt evidence-based models to account for moderators, including social factors, which are known to impact intervention effectiveness. Services research and implementation science strategies that test adaptations should be designed to determine 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 in mental health services use, delivery, and outcomes. Populations experiencing limited access to mental health care may include people with serious mental illness and people experiencing instability in housing, employment, 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 improved outcomes in all populations, NIMH will support research to develop innovative services delivery models that employs the following Strategies:

Strategy 4.3.A : Adapting, validating, and scaling-up programs currently in use that improve mental health services for populations who receive limited mental health services 

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 English language proficiency, educational, or cultural barriers; sexual minorities; individuals living with disabilities; 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, qualitative methods) 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; reduce the shortage of culturally and linguistically competent care providers for racial and ethnic minorities; reduce the workforce shortages in certain geographic areas (e.g., underserved rural communities); and, promote care that is respectful.

Strategy 4.3. B: Developing and validating service delivery models that provide evidence-based care for individuals throughout the course of mental illness 

Interest areas include:

1. Developing and testing innovative strategies to promote early identification and engagement in prevention and mental health or supportive services for children, adolescents, and adults, especially for those experiencing early symptoms of mental illness.
2. Characterizing care pathways to identify mutable barriers, facilitators, and social and structural factors to improving access to care across the lifespan, including children at risk for autism or mental illnesses, transition-age youth with autism or emerging mental illnesses, and adults with autism or mental illnesses.
3. Addressing workforce shortages, instilling hope and re-moralization, improving engagement with care and reach of interventions using paraprofessionals, peer providers, and nontraditional staff.

Strategy 4.3. C:  Developing and validating systems-level strategies, using technology and other approaches, to identify, support, optimize, and monitor the effectiveness of evidence-based care throughout the course of illness 

Interest areas include:

1. Using technology to improve prevention and early detection of mental illnesses, connect clients across all ages to evidence-based care, increase reach of and engagement with services, 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 and optimize 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, sustainability) in low-resource settings or non-specialty settings where significant unmet need exists (e.g., the criminal and juvenile justice systems, employment settings, military or veteran organizations, schools, 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).

Strategy 4.3. D: Developing and validating decision-making models that bridge mental health, medical, and other care settings to integrate the appropriate care for people with serious mental illness and comorbid medical conditions

Interest areas include:

1. Developing and testing service delivery models for people with comorbid conditions (e.g., medical comorbidities, co-occurring substance use disorder), such as care decision models that integrate treatment for mental illnesses and medical conditions, and service delivery interventions to reduce modifiable health risks associated with premature mortality in people with serious mental illness. These innovative service delivery models should be feasible in a wide range of settings, including low-resource settings, and acceptable to a wide variety of health disparity populations with a greater prevalence of comorbidities.²⁴
2. Developing and validating decision-support tools to assess mental health and functional needs, medical risk factors, and mental health/medical treatment availability in non-specialty settings where children and adolescents are served, and to facilitate treatment planning.
3. Using existing and developing novel technologies (e.g., mobile devices, information systems, artificial intelligence) to significantly improve access, engagement, quality, effectiveness, and efficiency of integrated mental health services, while making sure that these advances benefit people with a wide range of backgrounds, socioeconomic status, ethnicity, race, disability, and geographical area of residence.
4. Investigating strategies for active symptom management that reduce the symptom burden in individuals with serious mental illness and multiple chronic conditions.

Learn about the progress NIMH has made toward Goal 4 of the NIMH Strategic Plan for Research: Advance Mental Health Services to Strengthen Public Health.

Developing Tools for Measuring Mental Health Outcomes
The National Institutes of Health has funded six projects to develop, test, and validate outcome-focused quality measures for mental health, which are used to understand the impact of interventions when implemented in real-world health care systems and settings.

Primary Care Can Play Key Role in Suicide Prevention
Adding suicide care practices to routine adult primary care visits reduced suicide attempts by 25% in the months after the visit.

Improving Firearm Safety in Pediatric Primary Care
An automatic reminder supported by low-burden facilitation increased delivery of a universal secure firearm storage program during pediatric primary care.

Understanding the Availability of Mental Telehealth Services
In an NIMH-funded study, researchers examine the availability and structure of mental telehealth services.

Basic Research Powers the First Medication for Postpartum Depression
Decades of NIMH-supported basic research led to a pioneering treatment for postpartum depression and continues to power exciting advances in women's mental health care.

Revolutionizing the Study of Mental Disorders
The Research Domain Criteria Initiative (RDoC) represented a new way to conceptualize the study of mental illnesses. In celebration of NIMH's 75th Anniversary, we reflect on the beginning and progress of this initiative.

Using Games to Explore the Mind
The National Institute of Mental Health (NIMH) and the non-profit organization The Many Brains Project partnered with the National Institutes of Health (NIH) All of Us Research Program to adapt a series of new game-like tasks that are now part of the All of Us Research Program’s participant experience.

Saving Lives Through the Science of Suicide Prevention
Evidence-based efforts to improve suicide risk screening, assessment, and intervention are helping to save lives, thanks to research supported by NIMH.

Emergency Department Intervention Reduces Adult Suicide Risk
Evidence-based practices for suicide prevention effectively reduced suicidal behaviors among adults seen for care in emergency departments.

RAISE-ing the Standard of Care for Schizophrenia: The Rapid Adoption of Coordinated Specialty Care in the United States
The Recovery After an Initial Schizophrenia Episode research initiative, launched by NIMH to test the effectiveness of coordinated specialty care to treat first-episode psychosis, has transformed the mental health landscape in the United States and helped thousands of people with schizophrenia achieve better outcomes.

Youth Emergency Department Visits for Mental Health Increased During Pandemic
Hospital visits for urgent mental health care increased among children and teens in the second year of the COVID-19 pandemic, according to an NIMH-supported study.

Medicaid Data Show Wide Differences in Mental Health Care in the United States
A new NIMH-supported study revealed differences in rates of mental health care among Medicaid enrollees based on where they live in the United States.

Multistage Autism Screening in Early Intervention Settings May Reduce Disparities
An NIMH-supported study shows that incorporating a multistage screening process for autism spectrum disorder (ASD) into federally funded early intervention services may reduce disparities in early ASD diagnosis.

NIH Initiative Expands Access to Resources for Early Psychosis Treatment and Research
The Early Psychosis Intervention Network (EPINET), an NIMH initiative aimed at determining how to best provide treatment for individuals experiencing symptoms of early psychosis, is increasing access to resources for researchers, providers, and families through a growing network of research hubs and a new website.

NIMH Awards Funding for Research on Preventing Firearm Injury and Mortality
Suicide attempts by firearm are especially dangerous, with as many as 9 out of 10 attempts resulting in death. NIMH is supporting three projects focused on preventing and reducing firearm injury and mortality to help address the critical need for more research in this area.

Emergency Drug Overdose Visits Associated with Increased Risk for Later Suicide
A new data analysis has found patients who visited the emergency department for an opioid or sedative/hypnotic drug overdose were at higher risk of dying by drug overdose or suicide in the year after being discharged relative to the general population.

Developing Rapid, Accurate Assessment of Mental Disorders, Suicide Risk in Youth
For many adults who have a mental disorder, symptoms were present—but often not recognized or addressed—in childhood and adolescence. Early treatment can help prevent more severe, lasting impairment or disability as a child grows up.

Using Technology to Help Predict Binge and Purge Episodes in People with Eating Disorders
In binge-eating disorder and bulimia nervosa, people experience recurrent and frequent episodes in which they eat unusually large amounts of food and feel a sense of loss of control.