Despite the growing evidence supporting the benefits of coordinated specialty care (CSC) for early psychosis, access to this multimodal, evidence-based program in the United States has been hindered by a lack of funding for core CSC services and activities. The recent approval of team-based reimbursement codes by the Centers for Medicare and Medicaid Services has the potential to fund substantially more CSC services for clients with insurance coverage that accepts the new team-based billing codes. This streamlined and more inclusive billing strategy may reduce administrative burden and support the financial viability of CSC programs.

AIM:Community participation in occupational, social, recreational, and other domains is critically important during young adulthood. Coordinated Specialty Care (CSC) programs provide developmentally tailored care to young adults experiencing early psychosis within the United States, but little is known about the breadth of efforts to promote community participation. This study aimed to develop and evaluate indicators of these efforts based on the perspectives of a national multi-stakeholder group.METHODS:Seventeen stakeholders (i.e., young adults with early psychosis, family members, experts by profession) participated in a modified e-Delphi study, conducted in two rounds. The purpose of round one was to generate a comprehensive list of community participation-promoting indicators. During round two, stakeholders rated the importance and feasibility of the implementation of each indicator. Descriptive statistics and percentage of agreement regarding round two ratings were assessed.RESULTS:During round one, 186 indicators of activities and/or practices designed to promote community participation were identified; this list was reduced to 44 by eliminating redundancies or indicators not related to community participation. In round two, we found broad agreement regarding the importance, but significant variation in perceived feasibility of indicators. The highest-rated indicators in both categories pertained to staff knowledge (regarding barriers and supports to participation and the importance of participation to health) and strategies for addressing participation barriers.CONCLUSIONS:This study is expected to facilitate the identification and development of promising CSC activities and practices designed to promote community participation among young adults while potentially also enhancing engagement in services and improving clinical outcomes.

OBJECTIVE In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study. METHODS Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses. RESULTS Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge. CONCLUSIONS CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Abstract The field of public mental health has seen many advances in policy and discovery, yet there is much more to be done. We must move beyond a narrow focus on clinical interventions to now embrace the impact of community and population dynamics in promoting mental health, preventing mental illnesses, and fostering recovery. We must take advantage of emerging technologies, tools and strategies to expand discovery of the causes of mental illness that will inform new prevention and treatment strategies. Emerging tools can also guide the best implementation of individual and systems-level changes. Finally, we must continue to monitor the frequency of illness and related outcomes among individuals and populations to gauge our progress and highlight areas for continued improvement.

The aim of the study was to declare a call to action to improve mental health in the workplace.We convened a public health summit and assembled an Advisory Council consisting of experts in the field of occupational health and safety, workplace wellness, and public policy to offer recommendations for action steps to improve health and well-being of workers.The Advisory Council narrowed the list of ideas to four priority projects.The recommendations for action include developing a mental health in the workplace (1) "how to" guide, (2) scorecard, (3) recognition program, and (4) executive training.

Background: People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics. Methods: A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation. Results: An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents. Conclusions: The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation.

OBJECTIVE:The aim of the study was to declare a call to action to improve mental health in the workplace.METHODS:We convened a public health summit and assembled an Advisory Council consisting of experts in the field of occupational health and safety, workplace wellness, and public policy to offer recommendations for action steps to improve health and well-being of workers.RESULTS:The Advisory Council narrowed the list of ideas to four priority projects.CONCLUSIONS:The recommendations for action include developing a mental health in the workplace (1) "how to" guide, (2) scorecard, (3) recognition program, and (4) executive training.

Objective: Decision Aids (DAs) help patients participate in medical decisions. DAs can be in paper or digital format, but little is known about the readiness of people with psychosis to use digital technologies for decision-making in psychiatry. We evaluated attitudes and readiness for digital DAs among four stakeholder groups: people with psychosis, clinicians, caregivers, and administrators.Methods: Semi-structured interviews included 19 respondents: six people with a history of psychosis (clients), six clinicians, five caregivers, and two administrators. We recorded, transcribed, and coded interviews for themes using a qualitative inductive analytic process.Results: Our analysis revealed three key themes addressing readiness for involvement in an interactive digital decision-making: (1) preferences for paper DAs; (2) disadvantages of digital DAs (lack of computer skills, lack of access to digital devices, compounded by clients’ age and socioeconomic status); (3) advantages of digital DAs (accessibility to illiterate people or those with disabilities, decrease in cognitive burden).Conclusions: Our study suggests that the introduction of digital DAs into psychiatric medication consultations could be potentially well received. Appropriate training and access to digital devices may facilitate the adoption of digital DAs in mental health care.

The experience of adversity and toxic stress in childhood is associated with the development of chronic health and behavioral health problems. These problems contribute substantially to health care expenditures and the overall burden of disease. Although a strong scientific literature documents the effectiveness of primary prevention in reducing childhood adversity, promoting well-being and lessening the incidence of negative outcomes, funding for these interventions is highly fragmented across multiple government agencies as well as private and philanthropic sectors. It is becoming increasingly clear that improving population health will require a concentrated public health effort to improve access to and the accountability of these interventions as well as the development of novel financing schemes. In this perspective we review existing financing mechanisms for funding interventions known to reduce adverse childhood experiences and discuss innovative financing approaches that use insurance as well as pay-for-success funding mechanisms. The latter require that cost savings associated with primary prevention be quantified and that these savings be used to offset program costs, sometimes with a return on investment for private investors. We provide a series of recommendations regarding better coordination and strategic oversight of existing resources as well as the need to further develop and validate methodologies for estimating the societal costs and benefits associated with the varying social policies that are designed to ameliorate the effects of adversity and to build resilience.

Before the development of the germ theory in the late 19th century, infectious illnesses were largely uncontrollable and caused significant mortality. Implementing public hygiene, preventive, and treatment interventions created remarkable improvements in population health. Today's U.S. public health crises involve threats to health and human capital evidenced by multiple indicators of deteriorating wellbeing. These problems result from the interaction of risk and protective factors. Specifically, we argue that the interaction of genetic vulnerability and toxic stress are antecedents to a developmental cascade that undermines healthy development and human capital. We review relevant literature, summarize effective strategies to prevent or ameliorate this deterioration, and outline a theory of the mechanisms currently undermining our health. A series of strategies that we believe will constitute the next major era in public health are discussed, involving actions at the individual/family, community and societal level to reduce risk and strengthen protective factors. (PsycINFO Database Record

The demand for researchers to share their data has increased dramatically in recent years. There is a need to replicate and confirm scientific findings to bolster confidence in many research areas. Data sharing also serves the critical function of allowing synthesis of findings across trials. As innovative statistical methods have helped resolve barriers to synthesis analyses, data sharing and synthesis can help answer research questions that cannot be answered by individual trials alone. However, the sharing of data among researchers remains challenging and infrequent. This article aims to (a) increase support for data sharing and synthesis collaborations among researchers to advance scientific knowledge and (b) provide a model for establishing these collaborations using the example of the ongoing National Institute of Mental Health’s Collaborative Data Synthesis on Adolescent Depression Trials. This study brings together datasets from existing prevention and treatment trials in adolescent depression, as well as researchers and stakeholders, to answer questions about “for whom interventions work” and “by what pathways interventions have their effects.” This is critical to improving interventions, including increasing knowledge about intervention efficacy among minority populations, or what we call “scientific equity.” The collaborative model described is relevant to fields with research questions that can only be addressed by synthesizing individual-level data.

Click to increase image sizeClick to decrease image size ACKNOWLEDGMENTS Andrea Blanch was the coauthor on the paper in which we more fully develop this argument (Blanch & Shern, 2011 Blanch, A. K. and Shern, D. L. 2011. Implementing the new “germ theory” for the public's health: A call to action, Alexandria, VA: Mental Health America. [Google Scholar]).

In the wake of the latest mass shooting, there are calls to marshal the evidence and take steps to identify and treat mental illness early in life.

Abstract This chapter provides an overview of what can be done in the future to address the prevention and control of mental and behavioral disorders. It begins with a description of what has come before, examining progress and pitfalls. This is followed by a discussion of the evolution needed to bring about Winslow's vision of mental health care as an integral part of the public health. It examines the growing role of such factors as the social determinants of health; attention to the full spectrum of mental health and illness from prevention through recovery across the life span; the importance of resilience in preventing behavioral problems; the still evolving key role of consumers in treatment and recovery; and the policy changes needed to embrace mental health as an intrinsic part of the public health.

Comparative effectiveness research holds great promise for improving the care of people with mental health conditions and disorders related to substance abuse. But inappropriate application of such research can threaten the quality of that care. We examine the controversy surrounding a large real-world trial of schizophrenia treatments and conclude that the initial presentation of results led to overly simplistic policy suggestions that had the potential to harm patients. Patient advocacy groups helped illuminate these consequences and helped stimulate further discussion and analysis. Researchers must engage stakeholders, especially patients, in all aspects of comparative effectiveness research and translate the findings into sound mental health policy and practice.

Back to table of contents Next article Taking IssueFull AccessExamining Costs and Benefits in the Health Care DebateDavid Shern Ph.D.,David Shern Ph.D.Search for more papers by this author,Published Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.4.419AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Improving this country's very expensive and poorly performing health care system requires critical analysis of all health care expenditures and their attendant benefits. In a study reported in this issue, Valenstein and colleagues help frame the debate about costs and benefits of psychiatric care. These authors capitalized on the availability of comprehensive data from the VA health system to estimate the cost of implementing monitoring procedures that have been recommended by the FDA for reducing suicide risk in depression treatment.The authors estimate that the protocol would cost the VA system up to $270 million annually. Although this represents somewhat less than a 1% increase in the VA's health care budget, it is nonetheless a substantial sum. For example, it represents nearly half of annual federal expenditures for the Mental Health Block Grant, which helps to provide safety-net mental health services to the civilian population. The magnitude of the expense underlines the importance of understanding the validity of the FDA guidelines for preventing suicide and, perhaps, of the FDA's considering the costs of its recommended protocols in relation to anticipated benefits. Clearly, this admonition is relevant to the full spectrum of health care interventions, with treatments for psychiatric conditions being no more and no less important than other therapies. Some would criticize any consideration of cost in the face of a life-saving and clinically sensible intervention or would appropriately worry about including the cost of nonintervention. However, maximizing the efficient utilization of scarce health care resources requires that we understand all the costs and benefits.For these reasons, and given the elevated suicide risk for veterans and the expense of the FDA protocol, further research is needed. The availability of this large VA data set might provide the statistical power for a longitudinal, experimental analysis in which differing intensities of follow-up could be implemented with several samples and evaluated in relation to completed suicides or suicide attempts. Longitudinal research might also help to better identify individuals for whom this level of vigilance is merited and perhaps suggest a stepped approach to assessing suicidality with graded follow-up. Studies could investigate the use of automated methods to perform follow-up screening. Veterans would report their thoughts and feelings, which in some cases would trigger personal follow-up.Analysis of both costs and benefits must be part of the contemporary health care debate. Although recent congressional interest in comparative effectiveness research does not explicitly consider costs, it certainly anticipates such consideration. The cost analysis presented by Valenstein and colleagues highlights the importance of understanding differential effectiveness and of conducting research to develop evidence-based protocols that consider comprehensive costs as well as benefits.president and chief executive officer, Mental Health America FiguresReferencesCited byDetailsCited byNone Volume 60Issue 4 April, 2009Pages 419-419PSYCHIATRIC SERVICES April 2009 Volume 60 Number 4 Metrics PDF download History Published online 13 January 2015 Published in print 1 April 2009

Back to table of contents Previous article Next article Special Section on the Implications of STAR*DFull AccessSTAR*D: Helping to Close the Gap Between Science and PracticeDavid L. Shern Ph.D.Hazel MoranDavid L. Shern Ph.D.Search for more papers by this authorHazel MoranSearch for more papers by this authorPublished Online:1 Nov 2009https://doi.org/10.1176/ps.2009.60.11.1458AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The continuing gap between knowledge and practice is one of the most vexing problems facing our health care system. The 17-year latency period before consistent application of new knowledge to ordinary practice likely proves fatal for thousands of people each year ( 1 ). The gap stems from persistent problems in the training and support of clinicians as well as in the organization and financing of services. Addressing these problems will be a core challenge in efforts to reform health care. It is critical that this gap be closed. On Capitol Hill burgeoning political activity supports the use of systematic reviews and comparative effectiveness research to make decisions about policy and health care coverage. These efforts explicitly rely on rigorous and relevant scientific findings as well as on appropriate methods for synthesizing and interpreting scientific results.One aspect of these approaches that is not frequently discussed is related to the ways in which information is generated, synthesized, disseminated, and implemented. Because of strong cultural traditions in most biomedical disciplines, the randomized clinical trial is held as the gold standard for scientific inquiry. Clearly, this method is preferred when we desire to strongly demonstrate that a particular intervention can reliably produce a specific effect under particular circumstances. For many reasons, these circumstances are typically quite constrained, often involving homogeneous samples of volunteers who are treated systematically over a relatively brief period. The target outcome is generally a particular clinical marker, often at the symptom level. Persons are assigned to treatments without regard for their treatment preferences. Although all of these controls increase the likelihood of detecting a causal signal, they do little to inform us about the effects of the intervention in more representative situations, which has led to the distinction between efficacy and effectiveness trials. Efficacy involves demonstrating the effect under optimal, controlled circumstances, whereas effectiveness trials attempt to replicate these findings in real-world situations.STAR*D (Sequenced Treatment Alternatives to Relieve Depression) is one of several practical clinical trials that were launched by the National Institute of Mental Health (NIMH) to help remedy some of these concerns. From our perspective, STAR*D and its companion studies represent important advances in clinical research that enhance the results of both observational studies and randomized clinical trials. As such they are a critically important addition to our body of knowledge and have provided valuable information for consumers, clinicians, and policy makers. In this commentary we highlight some features and findings of STAR*D that have particular relevance for consumers seeking depression treatment in real-world settings and for advocates who work to ensure consumers' access to high-quality care.Relevance of STAR*D for consumers and advocates A few of the features of the STAR*D design are particularly noteworthy in regard to closing the gap between science and practice ( 2 ). STAR*D involved more than 4,000 participants, who were receiving care at 41 representative primary and specialty care clinical sites. The sample is more representative than the typical sample in a randomized clinical trial because minimal exclusion criteria were employed, thus permitting more subgroup analyses than the typical trial. Using remission rather than response to treatment as the clinical target helped to sharpen our thinking about outcomes and allowed for a better understanding of the trajectory of recovery. Use of a 12-month follow-up and multiple outcome measures across clinical, functional, and quality-of-life domains provided a framework for better understanding of the overall, more enduring effects of treatment. The design also allowed participants to choose among various strategies for medication augmentation or switching when their symptoms did not remit during the initial trial of citalopram. These strategies included the choice of another selective serotonin reuptake inhibitor at the level 2 intervention. This feature allowed for modeling and better understanding individual preferences for treatment than would have been the case with a standard trial design. Because of this flexible and complex design, STAR*D has provided a great deal of rich information that is important for individuals seeking help for depression, as well as for clinicians, advocates, and public policy makers ( 3 ). Perhaps most important for consumers is the finding that nearly 70% of participants who continued in the trial achieved remission at 12 months. However, nearly half of the individuals who would ultimately achieve remission did not do so until the second, third, or fourth levels of the trial ( 4 ). In addition, a significant number of the individuals who achieved remission did not do so during the first six weeks of treatment. For consumers STAR*D results indicate that if they stay in treatment and if the clinician takes a measurement-based approach to care, the odds are good that they will recover. However, more than six weeks of treatment may be required to determine its ultimate effectiveness. Practical trials such as STAR*D may ultimately help us better predict individual treatment trajectories and preferences by using biological and psychosocial markers, thereby realizing the long-desired goal of specifying which treatments work best for which individuals to achieve which outcomes. However, 30% of participants did not achieve remission after multiple interventions, and a large number of individuals dropped out of treatment ( 5 ). These results are cause for concern for advocates and researchers. The findings provide a strong rationale for additional research. Not only do we require basic and clinical research on prevention and treatment, but we clearly need services and implementation research to help us better design treatment approaches that increase participation and enhance quality. Practical clinical trails such as STAR*D provide an excellent format for addressing these services research questions. For policy makers STAR*D holds several important lessons. Strong cost containment pressures often lead to restricted access to the full range of treatments. The STAR*D results show that engaging persons in continuing care is critically important. Access barriers frustrate participation. In addition, because nearly half of persons seeking care for depression will require multiple medication trials and augmentation strategies, a full range of treatments must be readily available. Although restricting access to care might reduce short-term expenditures, such an approach is likely to do so at the expense of health and functional status—thereby increasing societal costs overall. Another policy-relevant finding involves the lack of any significant difference in outcomes between patients treated in the primary care or specialty care settings when a measurement-based treatment protocol is used ( 6 , 7 ). This is good news because most individuals seek care through the primary care sector. We must implement payment and regulatory strategies that create incentives for the use of measurement-based approaches in primary and specialty care. As in general health care, better health information technology holds great promise for improving the quality of care, which ultimately should reduce expenditures and improve health status. Finally, and perhaps most important, the clinical and policy implications of the STAR*D findings argue for increased use of such real-world designs and of similar contract research mechanisms at NIMH. It is unlikely that this extensive and expensive multisite study would have been developed as an investigator-initiated project. It also would probably not have fared well in the traditional review process for research proposals. In the same vein, the collection and use of phase IV trial data must be improved to better inform treatment. Advocacy groups such as Mental Health America are promoting increased consumer-patient participation in the design of clinical trials to ensure that their preferences and the outcomes that they value are considered.ConclusionsTo inform practice we desperately need more timely, accessible, and trustworthy information from multiple, representative settings. The STAR*D trial is an example of a research approach that can help close the gap between knowledge and practice. The consequences of not investing in this type of research greatly outweigh the costs of implementing it.Acknowledgments and disclosuresMental Health America receives unrestricted educational grants from Alkerms, AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, Forest Laboratories, GlaxoSmithKline, Janssen, Novartis, Noven, Otsuka, Pfizer, and Wyeth.Dr. Shern is president and chief executive officer of Mental Health America, 2000 N. Beauregard St., 6th Floor, Alexandria, VA 22311 (e-mail: [email protected] america.net), where Ms. Moran was affiliated when this work was done. She is currently associate director of government affairs, Eisai Corp. of America, Washington, D.C. This commentary is part of a special section on the STAR*D trial (Sequenced Treatment Alternatives to Relieve Depression) and the implications of its findings for practice and policy. Grayson S. Norquist, M.D., M.S.P.H., served as guest editor of the special section.References1. Institute of Medicine Committee on Quality of Healthcare in America: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academies Press, 2001Google Scholar2. Rush AJ, Fava M, Wisniewski SR, et al: Sequenced Treatment Alternatives to Relieve Depression (STAR*D): rationale and design. Controlled Clinical Trials 25:119–142, 2004Google Scholar3. Rush AJ: STAR*D: what have we learned? American Journal of Psychiatry 164:201–204, 2007Google Scholar4. Rush AJ, Trivedi MH, Wisniewski SR, et al: Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. American Journal of Psychiatry 163:1905–1917, 2006Google Scholar5. Warden D, Trivedi MH, Wisniewski SR, et al: Predictors of attrition during initial (citalopram) treatment for depression: a STAR*D report. American Journal of Psychiatry 164:1189–1197, 2007Google Scholar6. Gaynes BN, Rush AJ, Trivedi MH, et al: Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. General Internal Medicine 23:551–560, 2008Google Scholar7. Trivedi MH,Rush AJ, Gaynes BN, et al: Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology 32:2479–2489, 2007Google Scholar FiguresReferencesCited byDetailsCited ByWhy Is Exercise Underutilized in Clinical Practice Despite Evidence It Is Effective? Lessons in Pragmatism From the Inclusion of Exercise in Guidelines for the Treatment of Depression in the British National Health ServiceKinesiology ReviewHeart & Lung, Vol. 46, No. 3Introduction to the STAR*D Special SectionGrayson S. Norquist, M.D., M.S.P.H.1 November 2009 | Psychiatric Services, Vol. 60, No. 11 Volume 60Issue 11 November, 2009Pages 1458-1459PSYCHIATRIC SERVICES November 2009 Volume 60 Number 11 Metrics PDF download History Published online 1 November 2009 Published in print 1 November 2009

Practical clinical trials, such as STAR*D (Sequenced Treatment Alternatives to Relieve Depression), extend the traditional randomized controlled trial to real-world settings. Consumers and clinicians should be encouraged by STAR*D's 70% remission rate and should realize that for many participants remission required medication switching and augmentation. Policy makers should recognize the importance of easy access to a full range of treatments. Researchers should be sobered by the high attrition rate and the 30% of participants who did not achieve remission. Although more such practical trials are needed, future work must more meaningfully involve consumers in design, analysis, and interpretation.