The Connecticut Mental Health Center: Celebrating 50 Years of a Successful Partnership Between the State and Yale University

In 1966, the Connecticut Mental Health Center (CMHC) opened its doors in New Haven as a joint venture between the state and Yale University, codified by a memorandum of agreement that remains in effect today. Although Governor Abraham Ribicoff and the chairman of Yale’s Department of Psychiatry, Fritz Redlich, conceived the idea in the 1950s, the center’s creation was influenced by the Community Mental Health Centers Act of 1963, which added an emphasis on connection to the community (1). The tripartite missions of clinical care, research, and education remain the foundation for an organization that serves 5,000 individuals each year who are poor and who experience serious mental illnesses and substance use disorders.

Current clinical programs include inpatient and ambulatory services, assertive community treatment, community support, mobile crisis teams, “La Clinica Hispana,” substance abuse program, a young adult service, research specialty clinics, and integrated general medical and behavioral health care through the colocation of a federally qualified health center’s (FQHC’s) primary care clinic in the main building. CMHC serves as the lead agency for the Community Services Network, a collaborative of 15 community-based not-for-profit organizations providing housing, employment, social opportunities, and other core recovery supports. CMHC staff are frequently called upon by local community leaders and elected officials to provide consultation on program and policy development as well as rapid intervention.

Training programs for students and postgraduate professionals have flourished alongside the clinical and research initiatives. Medical students and physician associate trainees from Yale and other schools learn the basics of psychiatry, and pre- and postdoctoral psychologists and residents in psychiatry have the opportunity to develop advanced skills. Social work, nursing, and other students learn and work together on the interdisciplinary teams that form the core structure for each program. CMHC is also the site of several Yale advanced fellowships including addictions, law and psychiatry, neurobiological research, public psychiatry, and young adult psychiatry. Although some training programs are enhanced by federal funding, most are funded through the entity that funds the provision of clinical care—Connecticut’s Department of Mental Health and Addiction Services (DMHAS). This investment in workforce development has resulted in the successful recruitment of psychiatrists, psychologists, and other professionals into key positions within DMHAS and Yale.

The state resources, which CMHC faculty have leveraged for substantial extramural funding, enable a typically underserved population to receive innovative, first-rate care and generations of students and trainees to develop a deep appreciation for public psychiatry. The resources also support world-class research to shed light on the problems that cause our patients to suffer. The examples below highlight a few of the many initiatives that have emerged from this partnership.

Policy Development and Recovery-Oriented Services

Throughout the 1970s and 1980s, CMHC faculty and DMHAS leadership expanded their focus on developing community-based treatments and support services for people with serious mental illnesses. In the 1990s, Commissioner Thomas Kirk Jr., envisioned a service system that adopted recovery principles, and DMHAS invested in a new division, the Yale Program for Recovery and Community Health, to provide leadership and consultation for policy and program development, quality improvement, and training.

The vision of a “recovery-oriented system of care,” articulated and adopted in a 2002 commissioner’s policy, predated the 2003 report of the President’s New Freedom Commission, which called for a “transformation” of care to a recovery orientation. The commissioner’s policy informed the first consensus statement on recovery issued in 2004 and became central to the vision of SAMHSA shortly thereafter (2). Yale faculty drafted new policies, developed tools to assess and promote the provision of recovery-oriented and culturally competent care, and established a Recovery Institute for retraining the state workforce.

With the infusion of a SAMHSA Mental Health Transformation Grant, this work expanded to include identification and redressing of health disparities and creation of a consumer, youth, and family quality improvement collaborative. Several SAMHSA Access to Recovery Grants enabled DMHAS to expand earlier work to develop a robust array of recovery support services for persons with addictions. Paul DiLeo, DMHAS chief operations officer, and Commissioner Miriam Delphin-Rittmon have continued to build on this partnership by implementing a citizenship framework to complement the state’s recovery orientation and addressing social determinants of behavioral health, such as poverty, unemployment, racism, and other forms of discrimination, as barriers to community inclusion.

Ribicoff Research Facilities

When CMHC opened its doors in 1966, community-based care was possible primarily because of discoveries of medications that were effective in controlling patients’ disabling symptoms. Despite the efficacy of such treatments, their mechanistic basis, as well as the underlying pathophysiology of disorders they treated, were essentially unknown. The Abraham Ribicoff Research Facilities, including the Clinical Neuroscience Research Unit (CNRU) and the Neuropharmacological Research Laboratories (now known as the Laboratory of Molecular Psychiatry) were created to improve the understanding of the brain basis of psychiatric disorders, to develop new and more effective treatments based on such insights, and to train those who would make the next discoveries.

The Ribicoff Facilities have enjoyed considerable success, as evidenced by the strong and continued grant support from NIH and other federal, state, and private sources; the number and significance of research publications from its faculty; the number of national leaders trained by the Ribicoff Facilities; and most important, the major discoveries and new clinical treatments that have resulted.

One early example was the discovery of clonidine for opiate withdrawal. Basic researchers in the Ribicoff labs identified hyperactivity in noradrenergic neurons as a potential cause of such symptoms and discovered a new class of neuronal autoreceptors that might be targeted. The close working relationship between these basic scientists and clinical investigators in the Ribicoff Facilities led to rapid testing of clonidine, demonstration of its clinical efficacy, and dissemination of this new treatment nationally and internationally. A more recent example is the discovery of the rapid antidepressant effects of ketamine, which may be the most effective medication known for treatment-resistant symptoms of depression. These observations led to identification by Ribicoff researchers of the fundamental molecular pathway whereby such behavioral effects are mediated, a discovery that is leading to development of safer and more effective therapeutic agents, many of which are being tested in the CNRU.

Law and Psychiatry

In the 50 years of CMHC’s evolution, forensic psychiatry emerged as a subspecialty, encompassing new areas of expertise and specialized services. The Yale-state partnership has fostered program development, evaluation, and training to improve successful community reentry after incarceration for persons with mental illness, effective jail diversion efforts for those with psychiatric disorders, and treatment approaches to enhance engagement and risk management. New programs include a Community Forensic Treatment Team, which provides integrated psychiatric services, case management, and collaboration with probation and parole personnel to manage risk, prevent reincarceration, and promote recovery.

The partnership has contributed to numerous initiatives designed to manage risk, including the creation by statute of state positions for consulting forensic psychiatrists (CFPs), who monitor the treatment progress of persons found not guilty by reason of insanity and provide risk consultations for community agencies. The CFPs have all been graduates of the Yale Forensic Psychiatry Fellowship. Yale psychiatrists have served as statewide leaders, including medical director of DMHAS, director of the maximum-security hospital, and director of mental health services for the Department of Corrections, and have served on state commissions and boards overseeing the treatment of sex offenders, juvenile offenders, and prisoners with mental illness, as well as firearm permit revocations and reinstatement.

The Yale Forensic Psychiatry Division has provided Connecticut with innovative approaches, systematic evaluations of care, and expertise with respect to public safety and social justice. In turn, the state provides access to collaboration on critical issues, clinical placements for education, and standing in shaping policy and legislation.

Prevention and Systems-Based Community Approaches: The Consultation Center

The Consultation Center began in 1976 as a multidisciplinary service, research, and training site providing consultation and education services in the New Haven region. Today the Consultation Center focuses on prevention and systems-based community approaches to promote health and wellness, prevent mental health and substance abuse problems, and enhance equity and social justice in Connecticut, nationally, and internationally. Colocated with the Yale Department of Psychiatry Division of Prevention and Community Research, the Consultation Center is a site for postdoctoral research training for NIDA and for predoctoral training in clinical and community psychology.

An example of the Consultation Center’s work is its consultation with states and municipalities to implement and evaluate systems of care in behavioral health, juvenile justice, child welfare, and trauma-informed services. Another example is the development, implementation, and evaluation of prevention services that promote resilience in schools and communities for youths and young adults at risk of substance abuse. The Consultation Center conducts psychoeducational groups for adults arrested for domestic violence and helps organizations and systems build capacity for evaluation, usually in partnership with community stakeholders.

Early Intervention for Psychosis

The Specialized Treatment for Early Psychosis (STEP) program was launched at CMHC in 2006 (3) as a pilot coordinated specialty care service for young people and families confronting the new onset of a psychotic disorder. Clinical services were reallocated from an existing program, and outcome assessments were funded by NIH and foundation grants. In 2013, STEP personnel completed the first U.S. randomized controlled trial of such care, reporting a 48% reduction in risk of psychiatric hospitalization in the first year after entry, along with reductions in number and duration of hospitalizations. In 2014, funding from DMHAS allowed conversion to a permanent service. In 2015, STEP launched a three-year campaign to shorten the duration of untreated psychosis in ten surrounding towns. The Mindmap campaign, funded by NIH, includes media messaging, outreach to community stakeholders, and other approaches that aim to halve historical delays in care. The larger goal of STEP is to build a population health–based system of care, educate trainees and the public, and engage in discovery and implementation research to develop and disseminate effective treatments and models of care.

STEP is closely partnered with the Psychosis Prodrome Research (PRIME) Clinic, which was established at Yale in 1998 and which focuses on a period of illness lasting months to years before frank psychosis is apparent. Initially, PRIME conducted research aimed at determining who was truly at risk. Subsequently, criteria regarding prodromal symptoms and functional loss (4) were included in DSM-5 as attenuated psychosis syndrome. The integration of the clinical, research, and educational expertise of STEP and PRIME has facilitated proper diagnosis of borderline or ambiguous cases and rapid and effective treatment and has catalyzed research.

Latino Behavioral Health System

The Connecticut Latino Behavioral Health System (LBHS), based at CMHC and formalized in 2007 with additional state funding, represents a culturally informed community-academic collaboration. The mission is to expand and enhance the existing network of recovery-oriented and community-based services to ensure that behavioral health care is accessible and culturally and linguistically appropriate for Latinos throughout south central Connecticut. The LBHS efforts focus on two primary goals: workforce development and access to services.

Built on long-standing relationships and informed by consumers, family members, service providers, and program evaluation, the LBHS promotes ongoing collaboration among nine community-based organizations. The LBHS applies community knowledge, academic resources, and a multidisciplinary team approach to address disparities.

Addiction Medicine

Programs in addiction medicine began shortly after CMHC opened in 1966, at the time of an epidemic of opiate addiction stemming from the Vietnam War and widespread psychedelic drug use. Herbert Kleber, M.D., was awarded his first NIMH grant in 1968 and established the Drug Dependence Unit at CMHC—renamed the Substance Abuse Treatment Unit (SATU)—and this program remains robust. State support for addiction medicine was not available initially, so CMHC faculty turned to federal grant support for clinical research and education. In the 1980s, when the state began to contribute to the operation of SATU, the partnership became three way and has now grown into one of the leading academic addiction medicine programs in the United States.

The program has generated multiple innovative treatments for alcohol, opiate, stimulant, and nicotine addictions nationally and internationally. In addition, education of addiction medicine specialists in psychiatry, internal medicine, and psychology contributes to staffing public services throughout the country.

Conclusions

CMHC’s 50th anniversary is a cause for celebration of and reflection on the center’s many past achievements and its continued strength as a flourishing state-academic partnership. Its sustainability is bolstered by lessons learned over the years, including the importance of diversifying and leveraging funding sources, maintaining a focus on its core mission of serving individuals with serious mental and substance use disorders, and embracing change.

The partners share a commitment to excellence and innovation and a deep appreciation of the ways in which the three missions enhance each other. On the university side, a growing Division of Public Psychiatry propels the tripartite mission of CMHC. On the public side, state and federal leadership can count on the unique contributions that such a collaboration provides, including the training of new practitioners and leaders, discovery of evidence-based treatments, and translation of these treatments into recovery-oriented, person-centered care.