Experimental therapeutics is a framework focused on measuring whether experimentally manipulated, hypothesized targets of an intervention produce changes in clinical outcomes. For example, if a novel receptor is identified in schizophrenia and researchers believe that targeting that receptor would reduce paranoid delusions, researchers would then develop a drug targeting that receptor and test whether that drug reduces paranoid delusions. Although experimental therapeutics has generated a lot of excitement about highly individualized psychiatric treatments, there are questions as to its promise. Namely, such treatments have not produced the anticipated results despite ample funding support. Although psychiatry needs new models and innovations, the efficacy of experimental therapeutics as the path to identify these models and innovations remains questionable. therapeutics framework to the proposed work incurs additional prerequisites, namely, knowing why an intervention works to be considered for funding. The two perspectives selected for this column are both skeptical that having an experimental therapeutics perspective is productive, but they take different positions. Dr. Freed and coauthors advocate that experimental therapeutics frameworks take a more inclusive approach, highlighting the disadvantages of a narrow-door strategy. Dr. Rolin and colleagues argue that the experimental therapeutics framework should be replaced by a different framework that is based on desirability of outcomes. We hope that this exchange provides a useful perspective on a controversy that may not be on everyone's radar but has an impact on the pipeline of future therapeutics used to treat the patients psychiatrists serve.
Background: Mental health (MH) and substance use (SU) conditions generate large, multi-sector burdens. Health economics studies can guide smarter investment, but they tend to be conducted late in the research cycle and may omit costs and outcomes prioritized by affected communities. Community-engaged research offers practical ways to improve relevance and credibility by co-defining what counts as cost and benefit, how services flow, and what success means locally. Though health economics research includes many efforts to incorporate community voices, like Patient and Public Involvement (PPI) efforts, the field lacks specific guidance for engaging communities concerning mental health and substance use research, and little is known about the depth of involvement due to inconsistent reporting of community engagement efforts. Aims: To propose a formalized, MH/SU-specific approach for further embedding community engagement throughout health economics research-scoping, measurement, modeling, interpretation, and financing-where analyses substantially inform real-world decisions while preserving comparability to standard metrics. Results: We outline concrete steps that teams can adopt: (i) Complement early study activities with meaningful engagement including a brief plan that names partners, roles, decision rights, and compensation; (ii) Co-select costs and outcomes to elevate locally meaningful endpoints (e.g., housing stability, treatment retention) alongside standard measures (e.g., QALYs); (iii) Co-produce model structure and parameters aiming for a state-transition or stock-and-flow diagram or a "scenario bank" for sensitivity and threshold analyses; (iv) Match method to decision-CEA/CUA for comparability, CBA/ROI when cross-sector trade-offs must be monetized, and BIA when payers need near-term affordability; (v) Plan for implementation and financing, including documentation and contracting steps ("pilot-to-payment") and alternative funding paths for low-barrier models that operate with some measure of anonymity for clients (e.g., some recovery community centers or peer-run mental health organizations). Discussion and Implications: We recommend transparent reporting of engagement inputs and their effects on costs, outcomes, assumptions, and uncertainty, plus reciprocal practices (e.g., fair compensation, authorship where warranted, and plain-language briefs). Taken together, these steps can advance health economics research focused on MH/SU, helping the field to be more trusted, implementable, and likely to improve lives.
Background: The US Department of Veterans Affairs, Veterans Health Administration (VHA) launched the Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative in 2018, a large-scale implementation intervention to educate, motivate, and facilitate healthcare providers in primary care, pain, and mental health clinics (PC-P-MH) to prescribe buprenorphine for opioid use disorder (B-MOUD), with success. We compared healthcare cost outcomes for patients whose initial B-MOUD prescription originated in a SCOUTT clinic vs. a non-SCOUTT clinic. We also compared healthcare cost outcomes between PC, P, or MH SCOUTT clinics. Methods: We conducted a retrospective cohort analysis of electronic health record data from the Veteran Health Administration's Corporate Data Warehouse and Managerial Cost Accounting system. We identified veterans diagnosed with opioid use disorder (OUD) between 2016 and 2023 who received an initial B-MOUD prescription after 09/01/2018. We constructed a longitudinal dataset with quarterly data for patients spanning the two years prior to and two years following the index date, defined as the patient's first buprenorphine prescription. Outcomes included outpatient, inpatient, and pharmacy costs. We conducted a difference-in-difference analysis with patient and time fixed effects comparing outcomes before and after the index date between patients initiating buprenorphine in different settings. Results: Our primary analytic cohort included 3,573 patients with OUD. Among these patients, 1,202 (33.6%) had an initial B-MOUD prescription in a SCOUTT clinic. Quarterly pharmacy costs were $260 (p=0.044) higher on average for patients initiating B-MOUD in SCOUTT and non-SCOUTT settings over the two-year follow-up period. SCOUTT was also associated with lower inpatient, outpatient, and total costs during quarters shortly after treatment initiation. Restricting to SCOUTT clinics only, patients initiating B-MOUD in a MH clinic had $726 (p<0.001) greater outpatient costs and $1,908 (p=0.002) greater inpatient costs than those initiating B-MOUD in a PC clinic. Healthcare costs for patients initiating B-MOUD in PC and P clinics were no different. Discussion: Implementation strategies to encourage prescribing of B-MOUD in PC-P-MH settings, compared to SUD specialty clinics, promote short-term decreases in healthcare costs. Implications for Health Care Provision and Use: The SCOUTT initiative's expansion of buprenorphine treatment into primary care, pain, and mental health clinics was associated with stable total healthcare costs, reduced inpatient and outpatient costs shortly after initiation, and increased pharmacy spending consistent with appropriate medication use. These results suggest that decentralizing MOUD delivery can improve access and continuity of care without increasing overall healthcare expenditures. Implications for Health Policies: Supporting primary care and mental health clinicians to initiate and manage MOUD-through training, team-based models, and infrastructure such as SCOUTT- represents a scalable, efficient approach to addressing the opioid crisis within large healthcare systems like the VA. Implications for Future Research: Future research should examine treatment retention and clinical outcomes associated with SCOUTT implementation. In addition, studies linking to non-VA care data would paint a more complete picture of the impact of SCOUTT on total healthcare use.
Background: The per-child advance monthly payments of the expanded Child Tax Credit (CTC) of July-December 2021 were delivered to low-and middle-income households. Previous quasi-experimental studies have identified reduced depression symptoms for adults and adolescents associated with the expanded CTC. The monthly CTC payments may have also protected against mental health-related acute care visits or improved access to outpatient treatment. Aims of the Study: This study examined the effects of the CTC advance payments on mental health-related acute care utilization for adolescents enrolled in Medicaid in Ohio who were age-eligible for the CTC, relative to those slightly older who had aged out (i.e., turned age 18 in 2021). Methods: The study included Medicaid claims and enrollment data for adolescents enrolled in a Medicaid Accountable Care Organization, Partners For Kids, located in central and southeastern Ohio. Difference-in-differences analyses were used, comparing post-policy differences of the advanced CTC payments to pre-policy (2019 and January-June 2021) in two age groups, for whom we expected outcome trajectories to be equivalent, but for the CTC policy change. The first group aged out of the CTC (turned 18 in 4th quarter 2021; n=5,092), and the second was eligible (turned 18 in 1st quarter 2022; n=5,043). We also included two similar baseline age cohorts in 2019 (n=2,972 and n=2,994). Adolescents were included if they were enrolled at least 11 months of the calendar year. The primary outcome was any mental health-related emergency department visit or inpatient stay with a primary mental health diagnosis, and the secondary measure was any mental health outpatient care visit. A random effects logistic regression model tested a two-way interaction (CTC eligibility x CTC policy period) to evaluate the effect of the policy on primary and secondary outcomes. Subgroup analyses evaluated the effects for male and female adolescents separately. Results: Mental health-related acute care visits did not significantly change during the CTC advance payment period in 2021 (average marginal effect (AME)=-0.0006, CI-0.0018, 0.0006) for age-eligible adolescents compared to those not age-eligible. This pattern in mental-health related acute care visits was similar among male (AME=-0.0004, CI-0.0018, 0.0009) and female adolescents (AME=-0.0003, CI-0.0024, 0.0017). Mental health outpatient care visits also did not significantly change in 2021 for all three populations. Implications for Health Policies: The results do not provide empirical support for an association between the 2021 CTC payments and mental health-related outpatient or acute care among adolescents. The amounts offered in the per-child, monthly CTC advance payments may not have been sufficient to demonstrate an association in our sample, though our analyses for a rare acute care outcome may have been underpowered. Future research is needed to further assess the relationship between income-support policies, such as monthly cash transfers, and mental health care utilization among adolescents.
OBJECTIVE:Brief screening and triage tools are essential for reducing mental health disparities and for expanding access to care globally. This article describes the validation of the 13-item Mental Wellness Tool (mwTool-13) against routine psychiatric assessment in an acute care setting. METHODS:The mwTool-13 is a brief two-step questionnaire used to screen for the presence of psychiatric conditions and to stratify positive results into four categories: common mental disorders, severe mental disorders, substance use disorders, and suicide risk. The tool was administered to 269 patients receiving care in a psychiatric emergency department (ED); the tool's results were compared with the diagnoses made through routine psychiatric ED assessment. RESULTS:The tool's first step (three items) was highly sensitive in identifying the presence of any mental disorder (sensitivity=0.95). The sensitivity and specificity of the entire tool were, respectively, 0.97 and 0.67 for common mental disorders, 0.65 and 0.71 for severe mental disorders, 0.80 and 0.58 for substance use disorders (alcohol, drugs, or both), and 0.93 and 0.50 for suicide risk. CONCLUSIONS:With three items, the tool performed well in identifying the presence of any mental disorder. The complete 13-item tool performed well in identifying conditions and classifying them into common or severe mental disorders, substance use disorders, and suicide risk. The mwTool-13 can enhance early identification and triage of mental health needs in diverse settings.
