Delivery of Excellent Mental Health Care and Acceleration of Research: Federal Activities Since the President's Commission Report

In 2002 the President's New Freedom Commission on Mental Health was convened by executive order ( 1 ) to report on opportunities to "improve America's mental health service delivery system for individuals with serious mental illness and children with serious emotional disturbances." The commission's 2003 report, Achieving the Promise: Transforming Mental Health Care in America ( 2 ), contained a series of goals and recommendations designed to enable adults with serious mental illness and children with serious emotional disturbance to "live, work, learn, and participate fully in their communities." When considered alongside other seminal reports, such as the Surgeon General's 1999 report on mental health ( 3 ) and the Institute of Medicine's 2006 report on Improving the Quality of Health Care for Mental and Substance-Use Conditions ( 4 ), the commission's report provides an influential, authoritative, and consistent message regarding the need for dramatic changes in the way individuals with mental illness in this country are treated and cared for.

The conclusion of the Bush Administration is an appropriate time to reflect on the progress that federal agencies have made in achieving the goals outlined in the President's Commission report. A comprehensive overview of federal activities emanating from the commission's recommendations is both beyond our scope and has been presented elsewhere ( 5 ). This article seeks to highlight strategic federal government activities that have been specifically developed—or further advanced—to address recommendations included in goal 5 of the report's six overarching goals: "Excellent mental health care is delivered and research is accelerated."

Our current positions within two key federal agencies, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Mental Health (NIMH), as well as the first author's role as a senior policy adviser to the President's Commission, provide us with somewhat unique perspectives on the aftermath of the commission and its report. In many ways, the report's findings—and the commission's very existence—reflect important milestones in our nation's ongoing and collective journey to improve both the condition and the lives of individuals with mental illness. Yet what is particularly compelling—and hopeful—about the commission's report is its emphasis on transformation of the mental health system and the notion that each of us has an important function to fulfill if this transformative effort is to succeed in promoting recovery and full community participation.

With this in mind, we highlight examples of recent SAMHSA and NIMH activities that seek to promote the transformation of mental health systems by ensuring that excellent mental health care is delivered and research is accelerated. What follows are brief descriptions of key federally sponsored activities that underscore how both SAMHSA and NIMH have responded to the four recommendations outlined by the commission for goal 5.

Accelerate research

Recommendation 5.1 of Achieving the Promise is "Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illness." As the largest scientific organization in the world dedicated to research on the understanding, treatment, and prevention of mental disorders and the promotion of mental health, it can be argued that most of NIMH's annual budget is—directly or indirectly—devoted to carrying out this recommendation. Indeed, the mission statement in the new NIMH Strategic Plan ( 6 ) directly addresses this recommendation: "The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure." Rather than discussing the breadth of the NIMH research portfolio, we briefly present several recent activities that highlight the organization's interest in supporting research reflecting this recommendation. Consistent in these initiatives is the desire to ensure that effective interventions fit the needs of populations, community settings, and service systems, and as the NIMH Advisory Council report, The Road Ahead ( 7 ), suggests, research includes the partnership of key stakeholders (for example, consumers, families, providers, administrators, and advocates) working in concert to improve the mental health of the United States.

One recent NIMH research initiative—Recovery After an Initial Schizophrenic Episode, or RAISE—seeks to promote the recovery of individuals who have experienced a first psychotic episode and to interrupt the disabling progression of schizophrenia. In a recent request for proposals ( 8 ), NIMH called for the development and testing of a "comprehensive and integrated intervention that can be delivered in real world practice settings to promote symptomatic recovery, minimize disability, and maximize social, academic, and vocational functioning." Applications were submitted in August 2008, and after a comprehensive scientific and administrative review, the most competitive applications will receive funding to develop and pilot test the intervention, with a large trial to follow if preliminary results show significant consumer benefit.

A new NIMH request for applications (RFA) focuses on the recovery and resilience of combat veterans returning from Iraq and Afghanistan and calls for research on how services from community-based programs affect outcomes for veterans. The need for such services was documented in a recent RAND study that estimated that as many as a third of veterans returning from combat operations in Iraq and Afghanistan have mental health problems that warrant treatment ( 9 ). The RFA is soliciting applications for research funding to assess the impact of state and nonprofit community-based programs on veterans, particularly those who are not receiving services within Department of Defense or Department of Veterans Affairs (VA) programs, such as personnel from the army reserve and national guard and those recently separated from active duty ( 10 ). NIMH is interested in building the evidence base on the most effective ways to help this important population. The RFA set the first submission date in October 2008 and a second one in May 2009. NIMH intends to fund three to six new research grants.

Since the President's Commission report, SAMHSA's Center for Mental Health Services (CMHS) has also provided support to further define and operationalize recovery and resilience in ways that will improve the lives and prospects of persons with mental illness. A CMHS-sponsored national conference in December 2004 brought together more than 100 experts, including consumers, family members, researchers, providers, policy makers, and public officials, to produce a consensus statement outlining key principles necessary to the achievement of mental health recovery ( 11 ). Moreover, CMHS provides approximately $2 million annually to fund a network of consumer-support technical assistance centers that are an integral component of disseminating research and other materials related to mental health recovery and the prevention of mental illness ( 12 ).

Advance evidence-based practices

Recommendation 5.2 of the President's Commission report challenges the field to "Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation." The report further asserts that "The Nation must have a more effective system to identify, disseminate, and apply proven treatments or evidence-based practices (EBPs) to mental health care."

In response to this recommendation, SAMHSA has expanded and transformed its National Registry of Evidence-Based Programs and Practices (NREPP). NREPP was initially developed in the mid-1990s as a registry of substance abuse prevention interventions that documented their efficacy and effectiveness. For this early version of NREPP, well over 1,000 programs were reviewed, and about 150 were selected as worthy of inclusion as a model program on SAMHSA's Web site.

Partly because of the President's Commission report, NREPP underwent an extensive, multiyear transformation that, among other things, expanded the registry's focus to include interventions to prevent or treat mental illness. Launched in 2007, the redesigned NREPP system and Web site ( www.nrepp.samhsa.gov ) provides summaries of more than 100 mental health and substance use interventions. The summaries include descriptive information about the intervention and its targeted outcomes, expert ratings of the intervention's quality of research and readiness for dissemination, a list of studies and materials submitted for the experts' review, and contact information for the intervention developer. Users of the NREPP system can customize a searchable database to identify specific interventions on the basis of desired outcomes, target populations, and service settings. Current plans within SAMHSA call for continued expansion of NREPP at the rate of 40 to 50 new intervention summaries per year, with an overarching goal of providing agency constituents with information to inform decisions about selecting evidence-based interventions to address their particular needs and to match their specific capacities and resources.

Although the identification of evidence-based practices is a necessary step in expanding their use in routine clinical and community-based settings, true transformation will require "reframing reimbursement policies to better support and widely implement EBPs" ( 2 ). An inherent challenge in determining adequate reimbursement for the types of interventions included in NREPP—as well as reimbursement for interventions in the CMHS-sponsored evidence-based practices toolkits ( 13 )—has been the degree to which the various services that constitute these interventions can be reimbursed through more traditional public purchasers such as Medicaid and Medicare. Although solutions to this and other financing issues have remained somewhat elusive, staff from both SAMHSA and the Centers for Medicare and Medicaid Services (CMS) remain committed to achieving progress in this area, which is exemplified by a new initiative between SAMHSA and CMS to develop technical assistance for specific evidence-based practices. Moreover, although progress has been made in advancing specific practices, additional work is needed to develop and apply evidence-based (or evidence-informed) approaches to broader issues, such as effective dissemination and implementation strategies, and to systems change and redesign efforts.

For its part, NIMH has also been active in increasing the use of effective, evidence-based interventions. One major initiative has been to build the knowledge base on dissemination and implementation, the processes that most specifically improve the appropriate uptake of effective interventions in clinical and community practice. This area of science intends to bridge the gap between research and practice by developing and testing strategies to improve transmission of scientific findings and embed evidence-based interventions in real-world service systems. An NIMH program announcement in 2002 called for research applications that would "build knowledge on methods, structures, and processes to disseminate and implement mental health information and treatments into practice settings" ( 14 ). More recently, NIMH has expanded the scope of the program announcement to include research across multiple disease categories, in recognition of the fact that the facilitators and barriers to dissemination and implementation cut across disease categories. The latest announcements—PAR-07-086, PAR-06-520, and PAR-06-521 ( grants.nih.gov/grants/guide/pa-files )—now include participation from the National Cancer Institute; National Institute on Drug Abuse (NIDA); National Institute on Alcoholism and Alcohol Abuse (NIAAA); National Heart, Lung, and Blood Institute; National Institute of Dental and Craniofacial Research; National Institute of Deafness and Communication Disorders; National Institute of Nursing Research; and two National Institutes of Health (NIH) offices—the Office of Behavioral and Social Sciences Research and the Office of Dietary Supplements. Researchers who apply for these funds are encouraged to build knowledge to address the challenges of embedding complex interventions in service settings and to develop new strategies that overcome attitudinal, financial, and systemic barriers to achieving widespread use of beneficial interventions.

NIMH's current portfolio of dissemination and implementation research grants includes funds for small and large research projects and research centers and career development awards. To improve the dialogue among researchers interested in dissemination and implementation research, the participating NIH institutes have jointly held an annual scientific conference in Bethesda, Maryland, which brings together hundreds of investigators to present research findings, discuss methodological and theoretical challenges, and receive technical assistance from NIH program staff. The first meeting, "Building the Science of Dissemination and Implementation in the Service of Public Health," was held in September 2007 ( 15 ). The most recent meeting, "Science of Dissemination and Implementation: Building Research Capacity to Bridge the Gap From Science to Service," was held in January 2009 on the NIH campus ( conferences.thehillgroup.com/obssr/di2008/index.html ).

Improve and expand the workforce

Recommendation 5.3 seeks to "Improve and expand the workforce providing evidence-based mental health services and supports." Recent surveys of graduate and professional training programs have revealed that few require both didactic and clinical supervision in evidence-based treatments ( 16 , 17 ). Obstacles identified in these surveys included lack of qualified faculty, lack of trainee interest, and substantial research demonstrating that factors other than specific evidence-based approaches are primarily responsible for therapeutic change ( 18 ).

Nevertheless, SAMHSA recognizes that a competent and well-trained workforce is essential to providing effective, high-quality, and culturally relevant services to individuals who have mental and substance use disorders or who are at risk of developing them. In 2006 SAMHSA prioritized workforce development issues, which resulted in renewed attention and allocation of resources to this area. In addition, the agency published An Action Plan for Behavioral Health Workforce Development in March 2007 ( 19 ). Based largely on the pioneering efforts and expertise of the SAMHSA-funded Annapolis Coalition, the report comprehensively details the range of concerns related to workforce development both within behavioral health care and across general medical care and provides the field with wide-ranging and action-oriented recommendations for both improving and expanding the behavioral health workforce.

Of particular note, SAMHSA is nearing the launch of a new Web portal ( www.workforce.samhsa.gov ) to serve as a central repository for gathering and sharing up-to-date information and resources related to behavioral health workforce development. The Workforce Development Resource Center Web portal will contain searchable databases of educational and training opportunities; discipline- and state-specific licensure and certification requirements; and national, regional, and local job searches. In addition, the portal will house a virtual library of documents on a range of workforce development topics, such as best practices in recruitment and retention and the development of core competencies. By creating an interactive system that creates dynamic connections between individuals and organizations with workforce development needs and educational, training, and professional opportunities and resources, SAMHSA will help create and sustain a behavioral health workforce capable of responding effectively and compassionately to the increasingly complex and diverse needs of consumers and their families.

NIMH has also taken steps to promote workforce training. For example, in April 2007 NIMH sponsored a symposium with the Institute for the Advancement of Social Work, "Partnerships to Integrate Evidence-Based Mental Health Practices Into Social Work Education and Research." The meeting brought together representatives from the research community, social work educators, representatives from national organizations, federal agency staff, and consumers to discuss opportunities to promote the inclusion of training in evidence-based practices in university schools of social work. Presenters discussed existing training programs, state and school perspectives on training in evidence-based practices, and mechanisms to improve the partnership between educational institutions and service agencies ( 20 ).

In October 2007 NIMH, along with NIDA, NIAAA, and the NIH Office of Behavioral and Social Sciences Research, released an RFA titled "Programs of Excellence in Scientifically Validated Behavioral Treatments." The RFA offered funds for researchers to develop and test curricula to integrate training in evidence-based practices into university clinical training programs. In issuing the RFA the institutes recognized that although many evidence-based interventions have been demonstrated to be beneficial, few are being delivered by clinicians around the country. To increase the workforce capacity to deliver effective treatments, clinical training programs need courses that comprehensively prepare clinicians to deliver these interventions. Grants were awarded to a number of researchers who have developed the interventions, with the expectation that the investment will result in widespread dissemination of these curricula.

Develop knowledge in understudied areas

Recommendation 5.4 of the commission's report is a call to "Develop the knowledge base in four understudied areas: mental health disparities, the long-term effects of medication, trauma, and acute care." Commissioners agreed that research in these understudied areas is "essential to ultimately improve the quality of mental health treatments and services" ( 2 ). These areas of research are represented within the NIMH research portfolio, and the institute has developed specific research opportunities for growth. A few salient examples are noted here.

To reduce health disparities, the NIMH portfolio includes studies that attempt to reduce and ultimately eliminate disparities in prevalence, access, quality of care, and outcomes of treatment. This work cuts across all NIMH divisions, with coordination from the Office of Special Populations. In addition, NIMH has worked to increase involvement of underserved communities in the research process itself through an emphasis on community-based participatory research, which a recent program announcement (PAR-07-004) defines as "scientific inquiry conducted in communities with full partnership status for both community and academic researchers" ( 21 ). Mental health grants that use this approach have focused on implementing effective care within underserved communities, improving access to care, and adapting interventions to improve the applicability of treatments to specific populations. Another approach to reducing disparities that NIMH research has pursued is telemedicine. Several grants have used technology to provide services for people in rural and frontier settings. For example, a grant to the University of Arkansas for Medical Sciences is funding a study of the use of telemedicine to provide collaborative care in rural Arkansas.

Similarly, research on the long-term effects of medications, trauma, and acute care has remained an important component of the NIMH research portfolio. The practical clinical trials, such as Sequenced Treatment Alternatives to Relieve Depression (STAR*D), Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), and Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), have focused on selecting and sequencing the right medications and following up over time to gauge their longer-term effectiveness. NIMH initiatives in recent years have focused on understanding risk factors and appropriate treatments for posttraumatic stress disorder, including the current RFA on returning combat veterans, and efforts to improve the capacity of first responders to withstand the trauma experience. Finally, the NIMH has participated in several initiatives to improve the provision of acute care. One such program announcement, "Emergency Medical Services for Children," solicits research studies that target the reduction of mortality and morbidity among children seeking services in emergency departments ( 22 ). NIMH-funded research has looked at the emergency room as a setting for providing early mental health intervention, primarily through screening, assessment, and referral.

Although primarily a services agency, SAMHSA has also advanced knowledge in other areas. The agency's data strategy calls for collecting and reporting national information on the incidence and prevalence of mental and substance use disorders. Efforts are under way to collect national data on the prevalence of serious mental illness among adults through SAMHSA's National Survey of Drug Use and Health (NSDUH) and to develop prevalence estimates of serious emotional disturbance among children through the National Health Interview Survey of the Centers for Disease Control and Prevention. Recently, the NSDUH has provided estimates of serious psychological distress among various racial and ethnic groups, as well as racial and ethnic differences in use of mental health services and levels of unmet need for services. When examined over time, such data can provide an important tool for assessing the degree of progress in reducing or eliminating mental health disparities.

SAMHSA has also supported efforts to both expand and improve the delivery of trauma-informed services across the country. Since 2001 the agency has sponsored the National Child Traumatic Stress Network ( www.nctsn.org ), a unique collaboration of academic and community-based service centers. Their mission is to raise the standard of care and increase access to services for traumatized children and their families across the United States by developing and disseminating evidence-based interventions, trauma-informed services, and public and professional education. More recently, CMHS created the National Center for Trauma-Informed Care ( www.mentalhealth.samhsa.gov/nctic ) to offer technical assistance to stimulate and support interest in and implementation of trauma-informed care in publicly funded systems and programs. Through these and similar efforts, SAMHSA has demonstrated its commitment to using emerging knowledge and research findings to benefit those with or at risk of developing mental illness.

Next steps

The recommendations of the President's Commission on Mental Health reflect a fundamental vision of transformative change that would create a mental health service system that engages, supports, empowers, and strengthens every individual who receives care. As the activities described above suggest, SAMHSA and NIMH have embraced the commission's recommendations, particularly those of goal 5.

It is quite possible that broader forces, such as reductions and restrictions in public funding for health and social services, large numbers of uninsured and underinsured persons, and recent stresses on the domestic and global economies, have adversely affected both federal and state capacities to further achieve needed changes in mental health services and systems, although the effects of such factors are difficult to assess. Admittedly, such constraints force a reevaluation of what is practical and feasible with regard to mental health system transformation. However, as we are beginning to see, they may also provide new and unexpected opportunities to advance long-anticipated objectives related to broader health care reform and system transformation. If that is the case, then the activities of SAMHSA and NIMH described here may provide an important foundation for further progress in accelerating research and delivering excellent mental health care.

From our joint perspectives, continued advancement in goal 5 areas calls for renewed commitments to working across agency and organizational boundaries in ways that will ensure more rapid and widespread dissemination and implementation of key mental health research and policies while further developing and supporting vehicles to promote stakeholder influence in the pursuit and generation of new knowledge to understand and treat—and perhaps ultimately prevent and cure—mental illnesses. And if we fall short of "changing the world," to paraphrase Margaret Mead, at least we may be able to improve it measurably for those with mental illness.

Acknowledgments and disclosures

The views expressed are those of the authors and not necessarily those of SAMHSA, NIMH, or the U.S. Department of Health and Human Services.

The authors report no competing interests.