In 2007, the director (SME) of the Division of Mental Health Services and Policy Research (DMHSPR) at Columbia University–New York State Psychiatric Institute (NYSPI) and leaders of the New York State Office of Mental Health (OMH) instituted the OMH Policy Scholars Program to stimulate research projects of immediate practical significance to OMH with the primary goal of increasing the number of early-career researchers, particularly clinical scholars, pursuing policy-relevant services research. Because the health care issues and business challenges of OMH are similar to those faced by behavioral health delivery systems nationwide, projects funded under this initiative also are of high public health significance nationally, helping ensure that the scholar’s time investment is broadly relevant. This initiative is in the spirit of the 2006 National Institute of Mental Health (NIMH) report The Road Ahead: Research Partnerships to Transform Services (1).
The OMH Policy Scholars Program funds projects that are of policy relevance to OMH and small enough to be completed in one year. Ideally, these projects produce pilot data to strengthen grant proposals to NIMH and other funding sources on ways to identify, implement, and sustain new and effective policies or treatments.
Depending on the knowledge base in the research area, projects range from analyses of secondary data to creation of performance-monitoring tools, qualitative interviews with key informants, and pilot tests of new clinical interventions. To enhance feasibility and help ensure that findings will inform OMH’s practices, an OMH policy mentor is paired with each scholar. This mentor helps the scholar understand OMH’s mission and how to navigate a large public system. Policy mentors also facilitate access to administrators, data, information, and other resources necessary to conduct the research from OMH or its sister state agencies. Senior members of DMHSPR serve as research mentors (SME, TSS, DBH, and others), helping ensure that projects’ scope and design are reasonable for the time and resources available, and the DMHSPR administrator (AMS) helps scholars with institutional review board (IRB) submissions and budgeting. Scholars and mentors also present their work at the division’s weekly conference series.
The program’s application process is streamlined. [A Request for Proposals form is available online as a data supplement to this column.] The average award size is under $20,000 in direct costs, with wide variability across projects. About five to seven projects are funded each year, totaling approximately $100,000.
Because the scholars are typically junior and relatively inexperienced in the complexities of working in public mental health systems, they require substantial practical assistance, both to facilitate their work and to ensure that they pursue it in ways that are helpful to the programs hosting the research. One reason that research mentors are senior members of DMHSPR is so that they can help the scholar work effectively with OMH policy makers.
Because funding is limited to one year, project timelines are tight. Depending on the project, IRB approval may take several months, during which time the scholar, ideally, will become familiar with operations of the mental health system components that will be involved. Thus researchers have a narrow window to use the pilot funds, which also helps ensure that projects have prompt payoff for both researchers and public partners. The program may grant an extension for individuals who need extra time, but the goal is to design and deliver a small and useful research project quickly.
We describe two examples of research projects conducted by early-career faculty, both of whom were new to policy-relevant research. The projects resulted in research of direct relevance to OMH and led to publications and successful grant applications, helping ensure that the scholars pursue careers that generate timely improvements to mental health services. The case examples are of projects completed by psychiatrists who have both M.D. and Ph.D. degrees and whose doctoral training prepared them for research with a focus on basic science rather than on services. Other scholars have included psychiatrists, psychologists, social workers, sociologists, and economists from Columbia University’s College of Physicians and Surgeons, School of Social Work, and School of Public Health. [A list of scholars and their research topics is available in the online supplement to this column.]
Engaging individuals with hoarding disorder in treatment
A junior faculty member (CIR)—an assistant professor in the Anxiety Disorders Clinic (ADC) at NYSPI whose research focuses on developing novel treatments for individuals with obsessive-compulsive disorder and hoarding disorder—applied for an OMH Policy Scholars Program grant for estimating the community prevalence of hoarding disorder. The scholar applied for this grant during her postdoctoral research fellowship, mentored by the ADC director (HBS). She became interested in a newly proposed diagnosis for DSM-5, hoarding disorder (2), but needed pilot funding to start developing this new research direction.
Hoarding behaviors (such as difficulty discarding items and accumulating large volumes of clutter) so extreme as to be impairing are quite common, with lifetime prevalence estimated at 2%–5% (2). Behaviors cause public health problems and can lead to home eviction due to code violations, and thus they are of particular interest to OMH because they can cause homelessness in the population it serves. Even though these behaviors cause significant safety risks and effective treatments are available, including selective serotonin reuptake inhibitors and specialized cognitive-behavioral therapy, many individuals keep their disorder hidden until an emergency (for example, a fire) or threat of eviction attracts the attention of landlords or family members (3). In her grant proposal, the applicant hypothesized that the population seeking help from a community agency that serves individuals with housing problems would have a high prevalence of hoarding disorder and that these individuals might be unusually open to treatment when they contact the agency.
The study confirmed a high prevalence of hoarding disorder among 115 clients seeking help from the agency: 22% clinician-rated and 23% self-rated prevalence, about five to ten times higher than the general population prevalence (2%–5%) (4). Of the 25 persons who met criteria for hoarding disorder, 32% were currently in legal eviction proceedings, and yet only 48% were currently seeking mental health treatment (4). These results suggest that such community organizations may be a fertile site for identifying individuals with hoarding disorder when they may be unusually open to treatment.
The study was an important first step to gaining greater understanding of hoarding disorder, the associated eviction risk, and the timing of an effective intervention. Extending this work, the scholar used pilot data from the project to obtain a second OMH Policy Scholars Program grant plus a larger grant from New York Presbyterian Hospital Empire Clinical Research Investigator Program to develop a time-limited, novel evidence-based intervention for individuals with hoarding disorder. For this project, the scholar, with guidance from her policy mentor (AA, director of the OMH New York City field office) and research mentors in the ADC (HBS) and DMHSPR (DBH and SME) and in collaboration with providers identified via OMH, will pilot test an adaptation of critical time intervention (CTI) (5). CTI is an evidence-based, time-limited care coordination model that helps ensure continuity of support to persons with severe mental illness during critical transition points.
Through the OMH Policy Scholars Program project, the scholar generated two first-authored manuscripts and one external grant and developed new research collaborations with researchers from DMHSPR, the OMH field office, and community housing providers. In addition, this project strengthened the budding partnership between research in the DMHSPR and the ADC. The scholar is exploring these partnerships to further refine and evaluate the impact of the CTI adaptation, thus building on pilot feasibility studies and expanding her emphasis on services research while bringing knowledge and training about treating this disorder to community providers.
Engaging psychiatry residents in measurement-based care
A junior faculty member (MRA), associate training director for resident education in psychiatry, applied for an OMH Policy Scholars Program grant focusing on training psychiatry residents in measurement-based care and quality improvement. Her academic and research interests had moved from basic science toward medical education and health services delivery. She was interested in teaching residents how to “evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning,” a core requirement within residency training (6).
Despite increasing evidence of the ability of patient assessment instruments to influence treatment decisions and improve patient outcomes, few psychiatrists routinely use standardized assessments in their clinical practice (7). This scholar’s project included an initial survey of residents and supervising faculty regarding their opinions about using standardized patient assessments in clinical practice. She followed this with a three-week didactic seminar and year-long quality improvement project for residents aimed to increase depression screening and monitoring in the resident outpatient clinic. Within six months, residents showed an increase in screening from 4% to 92% of patients. In addition, they increased monthly monitoring of outpatients with diagnoses of depression from 1% to 76%. The scholar’s policy mentor was the OMH medical director (LIS), whose office oversees continuing education for hundreds of psychiatrists employed by OMH. Hence this match of scholar and mentor brought together individuals from the research and policy worlds who were both very interested in educational interventions to improve treatments provided by psychiatrists. The scholar’s research mentor (SME) provided guidance on implementation efforts.
The scholar received program grants for two more projects, building on this work by developing, implementing, testing, and disseminating an educational curriculum in quality improvement, with the OMH medical director continuing as her policy mentor. Even though there is a need to improve the rigor of education research, national funding for such research has been limited. Less than .04% of federal spending in graduate medical education is allocated to education research (8). Program funds were invaluable in launching this scholar’s research efforts. Her research has resulted in multiple national presentations, including workshops and posters, and in three first-authored papers currently under review or in press. In addition, the quality improvement curriculum developed from her research was selected by the American Association of Directors of Psychiatric Residency Training as a model curriculum.
Along with promoting measurement-based care in the emerging state workforce, this project provided residents with the skills necessary to adopt future evidence-based practices. As a natural extension of this work, the scholar turned her interest in quality improvement and training toward continuing medical education for practicing clinicians. She has continued to partner with her policy mentor (LIS) and research mentor (SME) and is now exploring linking OMH quality improvement initiatives with new maintenance of certification requirements established by the American Board of Psychiatry and Neurology, whereby practicing psychiatrists must now demonstrate ongoing participation in quality improvement (9).
This type of public-academic collaboration encourages early-career researchers to conduct policy-relevant mental health services research. The diverse perspectives of experts from the state and academic spheres have helped focus scholars’ research projects so that they have practical utility while also advancing scholars’ research careers. Given the evolution of the U.S. health care system (10), we will need to understand the impact of health care reform on individuals in need of mental health treatment and systems that serve them. This model of rapidly providing small grants for policy-relevant research is one way of developing scholars who are fluent in both research and policy making and who can facilitate communication and collaborations between researchers and health system administrators as they partner to transform services.
The OMH Policy Scholars Program was supported by funding from the New York State OMH. In addition, the sample projects described were supported by grants K23MH092434 (Dr. Rodriguez) and K24MH09155 (Dr. Simpson) from the National Institute of Mental Health, by the New York Presbyterian Empire Clinical Research Investigator Program (Dr. Rodriguez), and by NYSPI, a state hospital within the OMH system (Drs. Arbuckle, Simpson, Herman, Stroup, and Essock).
The authors report no competing interests.