The Maryland public mental health system values collaborative relationships among all system stakeholders. This is reflected by broad involvement of multiple groups at all levels of decision making and policy implementation. In keeping with this value, collaboration has also been a hallmark of the relationship between the Maryland Mental Hygiene Administration (MHA)—which is the state mental health authority—and the University of Maryland School of Medicine’s Department of Psychiatry (1–3). In the past decade, the Division of Services Research within the department has traded on the collaborative relationship to expand research within the public mental health system.
This column describes the Practice Research Network (PRN), a special project designed to facilitate widespread participation in research. It offers to other state mental health authorities and academic research departments a lesson in collaboration, using the tools afforded by such a network. Although the PRN builds on the unusually close relationships within Maryland, the model described in this column could be implemented in other locales with a different history of collaboration.
For many years, members of the faculty of the University of Maryland School of Medicine have conducted high-caliber psychiatric research. Most research participants, however, come from service providers closely affiliated with the Department of Psychiatry. As often occurs with academic research, the generalizability of some of the findings may be limited. Although the research has received much recognition in academic circles and in the national arena, both the university and the MHA have been aware that research findings are slow to be adopted by clinicians, at times because the external validity of the results is questioned (4).
In 2008 the PRN was created to address this problem. The project is funded by a grant from the Interventions and Practice Research Infrastructure Program (IP-RISP) of the National Institute of Mental Health. The fundamental goal of the PRN is to engage university investigators with public mental health system stakeholders to promote greater understanding of and involvement in research. The PRN’s efforts are expected to increase demand for research-supported interventions by consumers and family members and promote greater receptiveness to evidence-based practices among providers through experience with new treatments and services under investigation. PRN staff members also facilitate the involvement of a more diverse set of participants in funded research projects.
The academic entities included in the PRN are the Division of Services Research, the Maryland Psychiatric Research Center, and the Mental Illness Research, Education and Clinical Center of the Baltimore Veterans Affairs Medical Center. The leadership of these entities provides oversight for PRN activities and selects studies for support from among those presented to the PRN with requests for assistance. The PRN primarily links investigators with potential, interested research sites but is not involved in participant enrollment or study oversight. The PRN staff includes a part-time project manager and two full-time, paid liaison staff members. The liaisons were chosen because they both had previous experience as mental health clinicians and as research project staff.
A unique role: the PRN liaison
The PRN liaison is a catalyst for change, fostering partnerships between two fundamentally different systems—one includes researchers and study team members, and the other includes clinical practitioners and advocacy organizations. Despite a shared interest and dedication to improve mental health treatments and increase service access for consumers, far too often these systems continue to work independently of each other. The PRN liaisons work within both the research setting and the mental health community setting to bridge the separation between individuals who typically prioritize research design and data collection methods and those who favor practical therapeutic applications for the consumers they serve and, within the realm of consumer advocacy, those who desire better treatment.
Compared with more traditional positions related to university-based research, the liaison role places a higher emphasis on the development of reciprocal relationships between the academic research and public mental health system environments. The liaison aspires to establish a new system, centered on shared decision making regarding all aspects of research study process. Partnerships between researchers and practitioners can close the gap, in the interest of ultimately improving consumer care and improving the ecological validity and clinical utility of research (4).
A change agent in the research community
Historically, university-based researchers have used well-established approaches to connect with community mental health agencies to enroll study participants. Many researchers have an existing network of local mental health sites (usually affiliates) that have established connections with the research institution and are the first point of contact to initiate recruitment. Study team members meet with program administrators to describe the research protocol, answer questions, address concerns, and determine the best method to implement study recruitment procedures. This approach has merit because potential participants are likely to be located and enrolled quickly (especially individuals who are already accustomed to research participation) and because project costs are usually mitigated due to the relative proximity of the recruitment and study sites and the minimal effort required to introduce new study opportunities to a program already familiar with research participation. Despite these advantages, this approach has inherent problems, including the lack of generalizability resulting from limited access to a diverse population sample, the unintentional creation of “professional research subjects,” and increased burden to mental health agency staff.
It was anticipated that the introduction of the PRN as a more scientifically sound approach to recruiting study participants would appeal to researchers. Initial communication with principal investigators involves a face-to-face meeting, in which PRN liaisons use a structured interview tool to collect specific information and clarify the recruitment needs of investigators. They also describe strategies for providing PRN assistance with study implementation through site identification. The PRN uses this information to begin the task of promoting opportunities for study participation, ideally to a much broader geographical base (potentially statewide).
After the PRN was established in 2008, the PRN advisory group and liaisons faced the challenge of building a statewide infrastructure of sites within the public system interested in a sustained, mutually beneficial partnership with the PRN while meeting immediate participant recruitment demands for studies already in progress. One legitimate concern of investigators has been the time needed to identify potential sites in light of the immediate need to recruit study participants.
A change agent in the public system
In the initial stages of relationship building within the public mental health system, the liaisons addressed the formation and maintenance of crucial partnerships with the Maryland local mental health authorities, known as Core Service Agencies (CSAs). CSAs closely monitor mental health services in their respective geographical areas. CSAs are experts at identifying all available mental health services and resources located within their regions and serve as primary access points to the provider communities and advocacy group affiliates. The partnerships fostered with the CSAs represent the foundation upon which the PRN community infrastructure is built.
CSA provider meetings afford the liaisons the opportunity to meet and present to key leaders from a wide variety of mental health community service and consumer advocacy settings. During the first year of activity, the liaisons introduced themselves and oriented those present to the PRN mission. The liaisons also learned about program-specific details that could be useful to link a provider site to a specific study. The meetings provided an opportunity for attendees to share their research interests, a good focal point for the creation of a reciprocal relationship. The liaisons shared information about other study topics with investigators to influence the next generation of research projects.
Over time an infrastructure emerged, one that provides a diverse population sample and handles multiple studies simultaneously. When working with members of the public mental health community, the liaisons are sensitive to expressions of specific interests, concerns about research participation, past experience with behavioral health research and participation, and sensitivity to potential obstacles or issues that impede study implementation.
Education became a pivotal focus in developing understanding within the mental health community. Through PRN efforts, researchers presented information about topics related to their projects at sites that were readily accessible to interested providers or larger professional associations. In particular, PRN visits to consumer-run wellness and recovery centers were welcomed. Lively discussions and open dialogue continue about the intricacies of research implementation and the stigma associated with research, and they serve to enhance the trusting relationship between potential participants and researchers.
The PRN’s interest in broadcasting research information to a larger constituency led to the development of a link on the Web site, Network of Care, a site especially designed to support consumers, which is also available to the general public (www.maryland-research.networkofcare.org). The site provides information on current studies, contact information for those interested in participation, links to university departments providing research opportunities, and a glossary of research terminology.
Although available data are not adequate to determine the overall effectiveness of the PRN, some figures on recruitment provide descriptive evidence of its feasibility. By facilitating access to current opportunities to participate in studies, the PRN has supported 12 different study protocols generating 896 potential participant referrals from a wide variety of stakeholders and geographical regions within the public mental health system. The breakdown by referral source is 450 from provider organizations, 123 from family organizations, 40 from consumer advocacy groups, 16 from the Network of Care Web site, and 267 from unspecified sources. After an initial year in which the PRN generated 42 referrals, 404 referrals were received in the second year of operation, and 450 were received in the most recent year (2011–2012).
The PRN has demonstrated its feasibility in recruiting study participants. Thus the project sought additional information about some of the broader objectives of the PRN in terms of promoting interest in research. In 2011 PRN liaisons developed and distributed surveys to gather feedback from involved members of the public mental health and research communities to evaluate PRN activity and impact. A total of 156 surveys were completed: 120 by consumers, family members, and advocates (consumer and advocacy group); 32 by mental health authorities and providers (provider group); and four by investigators and study team members. Results indicated that approximately 60% of the consumer and advocacy group had a better understanding of behavioral health research because of the PRN and an interest in participation after hearing about study opportunities. Over 60% of the provider group reported that the PRN was helpful to their organization. The balance of consumers involved in the survey had more neutral or negative responses. Fifty-five percent of the consumer and advocacy group and 54% of the provider group indicated that they had a more positive opinion of research participation in general because of their experiences with the PRN liaisons. Building enthusiasm for research participation remains a challenge, but there is reason for some optimism. Seventy-six percent of the consumer and advocacy group and 81% of the provider group were interested in learning more about what the PRN had to offer.
The success of the PRN over the past four years continues to build momentum for this approach. The development of the liaison role to create and sustain partnerships with investigators and public mental health system stakeholders has changed the focus of study recruitment. The PRN continues to provide study referrals and also offers a sustainable infrastructure that expands services, providing research education to stakeholders and effectively supporting the recruitment activities of research teams. Requests from investigators to involve the liaisons in the design of new projects provide further opportunities for liaisons to utilize their research expertise by being more actively involved in the entire research process from inception to implementation. Increasing the scope of PRN services to include other academic researchers, private mental health providers, and the emerging integration of addiction and general medical services with mental health care provides a comprehensive agenda from which many more could derive benefit. It will be a challenge, however, to continue the PRN without salary support for one or more liaisons when the IP-RISP grant ends.
Maryland has enjoyed a close partnership among key stakeholders within the academic community, MHA leadership, and the practice community. It is a small state with fewer than six million people in an area 100 miles wide and 250 miles long; even so, the PRN has focused most on the areas close to Baltimore and in the suburbs of Washington, D.C. Although circumstances in other locales may differ, they can emulate the approach. The PRN is a new tool for increasing research involvement and hopefully improving mental health care in Maryland. Only a formal evaluation can assess whether the PRN has achieved its loftier goals, but there is no question that research participation and referrals have increased. Other states and academic departments can learn more about each other and work more closely together over time. With dedication to common goals this partnership can last for decades.
This work was supported by grant 5R24 MH082755 from the National Institute of Mental Health.
Dr. Buchanan has served on advisory boards of or as a consultant to Abbott Laboratories, Amgen, Inc., Astellas Pharma US, Astra-Zeneca, Bristol-Meyers Squibb, Cephalon, Inc., Cypress Bioscience, Inc., Envivo Pharmaceuticals, GlaxoSmithKline, Janssen Pharmaceuticals, Inc., Merck, NuPathe, Inc., Pfizer, Inc., Otsuka Pharmaceutical Co., Roche, Solvay Pharmaceuticals, Inc., and Takeda Pharmaceutical Co. The other authors report no competing interests.