AcademyHealth invited longtime member Donald Steinwachs, PhD, Health Policy and Management professor at the Johns Hopkins Bloomberg School of Public Health, to reflect on the recent release of the National Institute of Mental Health "Strategic Plan for Research." Dr. Steinwachs is a former AcademyHealth board member and the recipient of our 2013 Distinguished Investigator Award. His post follows.
Recently, Dr. Insel shared a vision for NIMH’s future science that has four objectives, two of which are aligned with health services research (HSR). Objective 3 is to strive for prevention and cures of mental illnesses. Strategies include developing new treatments, tailoring existing and new treatment interventions to optimize outcomes, and to test these interventions in the real world community practice settings. One can envision research teams of clinical and basic scientists working with health services researchers in the evaluation of tailored and new interventions in community practice settings. The HSR field understands that there are many factors that influence the effectiveness of mental health interventions, including characteristics of the practice, its capacity for outreach and follow-up, engagement of the consumer’s family and support network, and the extent to which the consumer’s basic needs are being met for income, housing, and comprehensive health care. An important part of the science to be learned through the translation of clinical interventions into real world settings will be how to tailor delivery of health services to overcome the many barriers persons with mental illness face in accessing care and adhering to treatment over time.
Objective 4 is to strengthen the public health impact of NIMH supported research. The strategies very much reflect an HSR orientation, including (1) research to improve the efficiency and effectiveness of mental health services, (2) establishing research-practice partnerships with a continuous quality improvement emphasis, (3) developing innovative service delivery models to meet the varying needs of diverse communities and populations, and (4) assessing the public health impact of mental health services innovation. To me the public health impact is central to measuring success and identifying and learning when interventions fail to improve public health. I remind myself frequently that persons with serious mental disorders have a life expectancy of about 55 years and their leading causes of death are the same leading causes all of us will die from but many years later. Dr. Insel discusses preemptive medicine as important for reducing the burden of mental illness and improving recovery. This needs to be extended to include comprehensive preemptive care for medical and preventive services for persons with mental illness. Public health impact assessment should take into account the person’s health and wellbeing as key outcomes, not just morbidity and mortality. Progress has been made to improve wellbeing. More mentally ill are able to get jobs today thanks to evidence-based supported employment interventions. Success is limited, however, due to lack of funding by health insurers and by states for supported employment interventions.
I find the NIMH strategic objectives to be exciting but am concerned about the capacity of NIMH, AHRQ, PCORI and others to fully fund the research needed. The personal and social costs to society of mental illness are not widely appreciated. We only need to remember the burden of mental illness; one quarter of us have a mental-emotional problem at any time and half of us having a mental illness during our lifetime.