Clinical Mental Health Services Research Articles

Shared care in mental illness: A rapid review to inform implementation

BackgroundWhile integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders.MethodsA rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of s of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists.ResultsShared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services.Conclusions"Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.

Clinician experiences of employing the AmpliChip® CYP450 test in routine psychiatric practice

These findings are from a qualitative study examining clinician experiences of employing the AmpliChip® CYP450 test in psychiatric practice. One hundred tests were made available to secondary care mental health service clinicians commencing patient treatment with risperidone across three District Health Boards within New Zealand. Feedback was sought on clinicians' (n = 33) experiences of ordering the test and receiving results, utilization of results, and perceived advantages and disadvantages. Difficulties were reported regarding ordering the test and receiving the results; however, real or perceived advantages of employing the test results in practice were widely reported. Analysis of the ways in which the test results were reportedly utilized revealed that they generally played a supporting role with regard to dosing decisions, rather than being the main influence on clinician behaviour. The test itself, and subsequent results, was viewed as potentially useful in facilitating the development of the doctor-patient relationship. Reported disadvantages of the test included potential over-reliance at the expense of clinical wisdom, cost, and challenges inherent in introducing a new clinical procedure into routine practice. These findings indicate that psychiatric clinicians are receptive to employing this test as a clinical support tool if its implementation is carefully considered and economically justifiable.

FC04-01 Development of an instrument to measure the level of evidence-based practice in clinical mental health services

Introduction:While systems of care are identifying the need to employ evidence-based modes of treatment, there are to date few instruments designed to measure the degree to which clinicians apply evidence-based interventions. The interventions survey was designed to tap each clinicians’ understanding of evidence-based interventions and the degree to which they identify theory in relation to evidence-based intervention and diagnosis.Method:A literature review was conducted to identify evidence-based interventions. Search strategies included meta-analyses that focused on systematic review of a range of databases. Emphasis in the survey's design was placed on linking evidence-based interventions, diagnosis and theoretical orientations. Clinicians (n = 118) could select among a range of options including evidence-based interventions for specific diagnoses. In addition to mapping evidence to interventions by diagnosis, results include a report of index modal interventions used by staff by type (individual, group, family) and diagnosis. The higher the index reported (range 0-1) the greater the variation of interventions by diagnoses.Results:Forty percent of clinical staff favored more that one type of family therapy for different diagnoses, and 35% of staff favored more than one type of group therapy for different diagnoses, whereas about 30% of staff varied their choice of individual intervention as a function of diagnosis.Conclusions:The results indicate that the survey is able to tap a range of clinicians’ theoretical orientations and knowledge of evidence-based practices related to child and adolescent mental health interventions.

Guidelines for treating mental illness: love them, hate them. Can the SIEP-DIRECT's Project serve in the search for a happy medium?

This paper discusses some key aspects of the debate on the difficulties of incorporating scientific evidence into the daily work of clinicians in mental health services (MHS). It highlights the topics of: the utility of guidelines in this field, the ethical principles that should guide their utilisation, their limitations, obstacles impeding the diffusion of guidelines in psychiatry, and strategies that can be useful for overcoming the barriers to guideline implementation. The SIEP-DIRECT'S ((DIscrepancy between Routine practice and Evidence in psychiatric Community Treatments on Schizophrenia) Project's potential role in fostering this advancement is discussed in detail. This Project developed a set of 103 indicators that operationalised the NICE clinical guidelines for schizophrenia recommendations and tested them in 19 MHS in Italy. A multi-step design was used to assess recommendation and indicator acceptability in the Italian context; provide an assessment of any current discrepancies between routine practice and guideline recommendations in the treatment of schizophrenia; and understand the reasons for any discrepancies that might emerge. This process, moreover, was instrumental in keeping the debate arising during conduction of this Project far from the excesses of hostility - and excesses of "bright-eyed enthusiasm" - that frequently influence discussion on topic. This Project therefore showed potential to serve in the search for a happy medium, that can facilitate the pursuit of a fundamental advancement in guideline implementation in mental health services.

States Try Several Strategies to Expand Health Coverage

States Try Several Strategies to Expand Health Coverage

Crisis into Opportunity: Setting up Community Mental Health Services in Post-Tsunami Aceh

The Asian Tsunami killed more than 130,000 people and made 400,000 homeless in Aceh, an area in Indonesia already affected by over thirty years of conflict. This paper examines an approach taken by an International Non-Governmental Organisation (INGO) to address emergency mental health and psychosocial needs in an integrated way, by providing a continuum of care incorporating psychosocial support for the wider community and clinical services for the more severely affected. The model included outreach to the indigenous system. Psychosocial activities were developed in partnership with the local communities. Community-based clinical mental health services were established by identifying and building locally-based capacity at the primary health care level, and potentially sustainable services were established in collaboration with the Ministry of Health. By December 2005, four hundred and eighty three patients had been seen. More than one third suffered from serious mental disorders that predated the Tsunami. Thus, crisis provided an opportunity to address longstanding community mental health needs. The lessons learned from this approach are also discussed.

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

Transformational and Transactional Leadership: Association With Attitudes Toward Evidence-Based Practice

Leadership in organizations is important in shaping workers' perceptions, responses to organizational change, and acceptance of innovations, such as evidence-based practices. Transformational leadership inspires and motivates followers, whereas transactional leadership is based more on reinforcement and exchanges. Studies have shown that in youth and family service organizations, mental health providers' attitudes toward adopting an evidence-based practice are associated with organizational context and individual provider differences. The purpose of this study was to expand these findings by examining the association between leadership and mental health providers' attitudes toward adopting evidence-based practice.Participants were 303 public-sector mental health service clinicians and case managers from 49 programs who were providing mental health services to children, adolescents, and their families. Data were gathered on providers' characteristics, attitudes toward evidence-based practices, and perceptions of their supervisors' leadership behaviors. Zero-order correlations and multilevel regression analyses were conducted that controlled for effects of service providers' characteristics.Both transformational and transactional leadership were positively associated with providers' having more positive attitudes toward adoption of evidence-based practice, and transformational leadership was negatively associated with providers' perception of difference between the providers' current practice and evidence-based practice.Mental health service organizations may benefit from improving transformational and transactional supervisory leadership skills in preparation for implementing evidence-based practices.

Police and Mental Health Collaborative Outreach

Back to table of contents Previous article Next article Frontline ReportsFull AccessPolice and Mental Health Collaborative OutreachSusan S. Erstling, L.I.C.S.W., Ph.D.Susan S. ErstlingSearch for more papers by this author, L.I.C.S.W., Ph.D.Published Online:1 Mar 2006https://doi.org/10.1176/appi.ps.57.3.417-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Clinical mental health services that are trauma informed are developing around the country. We adapted the Child Development—Community Policing (CDCP) model, which was developed at the Yale Child Study Center in conjunction with the New Haven police. The model brings clinicians immediately to the crime scene when police officers identify children who have witnessed violence. The clinicians provide intervention and follow-up to children who otherwise might be neglected or ignored after a critical incident. The goals are to attend to the children, acknowledge their exposure in a developmentally appropriate way, and decrease the impact of violence on their development.In Providence, Rhode Island, after one year of responding on scene to such violent episodes, Family Service of Rhode Island mental health workers and Providence police officers established a collaborative proactive outreach approach to providing early intervention, support, resources, and culturally relevant follow-up. At first, a native Spanish-speaking intake coordinator participated in standard police "ride-alongs," visiting families whom the police knew needed assistance even before a critical incident occurred.Later, funding was obtained through the Rhode Island Foundation to hire a Spanish-speaking mental health worker to ride along with police officers in a high-crime district three nights a week from 3 to 11 pm. Generally, a police officer and the mental health worker respond to all calls that occur in that district and visit with families and children that the officer has come to know through his or her community policing. The mental health worker has access to a licensed clinician on call at all times as well as additional staff if indicated.The role of the mental health worker in partnership with the police is to provide interpretation, crisis intervention, brief assessment and referral, support, and information. If appropriate she can conduct an intake for follow-up services.Common problems include parent-child conflict, runaways, domestic violence, parental depression, acting out among adolescents, gang affiliations, homicide, and parents' inability to manage their children. Many cases involve immigrants who do not understand how to gain access to mental health services and are more responsive to recommendations when someone speaks a familiar language.During the first six months of funding, the mental health worker rode with 42 police officers, and more than 100 clients were served. Spending eight hours in a car together, police officers and the mental health worker learn to trust each other, a sine qua non of work in the community. We hope this outreach program diverts participants from the criminal justice system.Dr. Erstling is vice-president of trauma, intake, and emergency services for the Family Service of Rhode Island, P.O. Box 6688, Providence, Rhode Island 02940-6688 (e-mail, [email protected]). FiguresReferencesCited byDetailsCited byNone Volume 57Issue 3 March 2006Pages 417-a-418 Metrics History Published online 1 March 2006 Published in print 1 March 2006

Differences in Clinical Features and Mental Health Service Use in Bipolar Disorder Across the Lifespan

Because of the scarcity of research in geriatric bipolar disorder, the authors examined the prevalence, clinical features, and service use of persons with bipolar disorder among older adults treated in a large public mental health system. From San Diego County's Adult and Older-Adult Mental Health Services database (N=34,970, fiscal year 2002-2003), the authors selected patients with bipolar disorder, divided them into three age-groups (young: age 18-39, middle-aged: age 40-59, and elderly: age 60+) and compared them on demographic, clinical, and mental health service use characteristics. The authors identified 2,903 patients who received services for bipolar disorder at least once during the fiscal year, accounting for a slightly lower proportion of diagnosis among elderly patients (7.0%) than middle-aged (8.7%) or younger groups (8.3%). Elderly patients were less likely to have substance use disorder comorbidity, but more likely to have a cognitive disorder diagnosis and lower global functioning scores than their younger counterparts. Elderly bipolar patients were less likely than younger groups to use inpatient, outpatient, and emergency room psychiatric care, but more likely to use case-management and conservator services. Bipolar disorder was only slightly less common among elderly patients in a large, public mental health system, compared to younger age-groups. Available clinical data revealed a mixed picture of bipolar disorder in late life, with more functional and cognitive impairment and less substance use disorder comorbidity and use of acute psychiatric services. Our findings suggest that older adults with bipolar disorder have unique mental health service needs.

Differences in Clinical Features and Mental Health Service Use in Bipolar Disorder Across the Lifespan

Differences in Clinical Features and Mental Health Service Use in Bipolar Disorder Across the Lifespan

Community care for people with psychosis: Outcomes and needs for care

People with psychosis living in developed countries in the era of community-based care are likely to be socially isolated, unemployed, and have poor quality of life, despite recent advances in the treatment and understanding of psychosis. Recent work in Australia illustrates the needs for care, especially for those with complex disabilities, and even for those in contact with well-organized clinical mental health services. Insufficient evidence in two key areas impedes progress: the use of effective psychosocial interventions; and the impact of changes in the community care system. Follow-up studies of programs and interventions assessing a range of outcomes in local settings are now required to encourage professionals and the community to address these needs.

Effects of patient and health-system characteristics on community tenure of discharged psychiatric inpatients.

The purpose of this study was to identify the differential effect of patient and health-system characteristics on length of stay in the community among recidivist psychiatric patients. Data on demographic and clinical characteristics and mental health service utilization were collected for patients with at least one previous psychiatric hospitalization (N=1,972) who visited a psychiatric emergency department at a university hospital in Leuven, Belgium, between March 2000 and March 2002. Logistic regression analysis was used to compare the characteristics of patients with a short (less than two months), intermediate (two to 12 months), or long (12 months or longer) stay in the community between their last hospital discharge and referral to the psychiatric emergency department. One in three patients visited the psychiatric emergency department within 30 days of discharge from a psychiatric hospitalization, and 43 percent of the patients visited within 60 days of discharge. Patients with a short community stay were more likely to be unemployed and to have had a discharge against medical advice, a short previous hospitalization, no aftercare plan, and a history of two or more previous hospitalizations. Longer community stays were predicted by the presence of a personality disorder. For patients with a history of psychiatric hospitalization, early psychiatric recidivism may be more highly influenced by health-system characteristics than by the presence of severe mental illness.

Commentary: School Psychology, Context, and Population-Based Practice

Ringeisen, Henderson, and Hoagwood 2003) have provided an important discussion of the significance of school context to children's mental health, particularly in relation to empirically supported interventions. They have outlined the influence of context on treatment integrity, and have emphasized appropriately the significant gap between research-supported interventions and practice. Finally, they have proposed a useful heuristic for conceptualizing context and practice from the individual to the organizational to the policy level. Their conclusion is that school context is a critical mediator in both research and practice, one that must be addressed to ensure successful children's mental health services. Although Ringeisen et al. (2003) deal with children's mental health and the school context thoroughly, they address the relationship between children's mental health and school psychology practice in somewhat less detail. In this commentary, I will examine some implications for school psychology practice of moving to a contextual perspective in children's mental health services, as outlined by Ringesein et al. School psychology is the specialty in American professional psychology that is most closely aligned with current, population-based thinking about children's mental health. However, to respond effectively to recent children's mental health policy, school psychology may need to expand the way services are conceptualized, planned, and delivered. Children's mental health is important to schools. As Ringeisen et al. (2003) note, relatively little systematic attention has been given to the effect of children's social and emotional problems on immediate educational outcomes, such as academic achievement. However, broader and longer term implications of children's mental health problems seem clear: Children with social and emotional problems are at much greater risk for dropping out of school and of subsequent problems in adulthood. Children with such problems often have difficulties with peer relationships, may present discipline problems, and often are disengaged from schooling and academic pursuits. They exhibit a higher incidence of family difficulties, which has a further impact on school functioning, and often have fewer resources available to them in the community. Even in the absence of data on the effects of social and emotional problems on short term educational outcomes, the cost to schools and society of failing to deal with these children is obviously--and distressingly--high (Short & Shapiro, 1993). Historically, American schools, as a context for addressing children's mental health problems, have maintained a reactive, often negative stance. Students in the United States are expected to conform to school roles and expectations; failing that, they typically either have been excluded from school or referred for clinical educational or mental health services. Exclusion from school merely relocates the child while depriving him or her of educational supports and services. On the other hand, clinical services are expensive, require substantial additional expertise and resources, and typically define problems as residing within the child, and therefore may fail to address critical contextual contributors to child problems. And, as Ringeisen et al. (2003) accurately point out, add-on program and resource requirements may have caused schools to be less willing to deal with children with social and emotional problems. The recent report of the Surgeon General's Conference on Children's Mental Health (U.S. Public Health Service, 2000) has provided an important framework that schools and school psychologists may use to build context-sensitive mental health services. Important components of this framework include: (a) All children develop socially and emotionally, as well as cognitively, and therefore have social and emotional needs that are as important as educational needs; (b) beyond the social and emotional developmental needs of all children, a smaller group of children have serious social and emotional problems; (c) addressing the social and emotional development and needs of all children likely lowers the incidence of children with expensive and difficult-to-treat social and emotional problems; and (d) schools are crucial both in addressing the social and emotional needs of all children and in providing services to that smaller group of children with social and emotional problems. …

Developing, delivering and evaluating interprofessional clinical risk training in mental health services

Aims and MethodThe need for training to prepare mental health professionals to assess and manage risks is now well established. This paper reports on the development, delivery and evaluation of interprofessional clinical risk training in Salford and Manchester since 1998. A training-needs analysis was carried out, followed by post-training evaluation and an impact-monitoring questionnaire.ResultsThe training was very well received by participants, with over 90% of them meeting the objectives and 100% of respondents reporting that the training had a positive impact on their clinical practice more than 12 months afterwards.Clinical ImplicationsThe evaluation of the training demonstrates that a properly planned and delivered 2-day clinical risk assessment course can have a positive impact on the practice of clinicians in mental health services. However, this should be seen only as an introductory course, as more advanced risk training is required. This is currently being delivered and planned.

Developing, delivering and evaluating interprofessional clinical risk training in mental health services

Aims and MethodThe need for training to prepare mental health professionals to assess and manage risks is now well established. This paper reports on the development, delivery and evaluation of interprofessional clinical risk training in Salford and Manchester since 1998. A training-needs analysis was carried out, followed by post-training evaluation and an impact-monitoring questionnaire.ResultsThe training was very well received by participants, with over 90% of them meeting the objectives and 100% of respondents reporting that the training had a positive impact on their clinical practice more than 12 months afterwards.Clinical ImplicationsThe evaluation of the training demonstrates that a properly planned and delivered 2-day clinical risk assessment course can have a positive impact on the practice of clinicians in mental health services. However, this should be seen only as an introductory course, as more advanced risk training is required. This is currently being delivered and planned.

Suggested principles of professional ethics for the online provision of mental health services.

The goal of this project was to suggest principles of professional ethics for the online provision of clinical mental health services that could guide clinicians who provide and patients who receive such services. A joint committee of the International Society for Mental Health Online (ISMHO) and the Psychiatric Society for Informatics (PSI) was formed. Discussion and development of these principles took place online. A set of principles was produced and endorsed by ISMHO on January 9, 2000, and by PSI on May 13, 2000. The principles involve informed consent (about the process, the clinician, the potential risks and benefits, safeguards, and alternatives), standard operating procedure (competence, legal requirements, the structure of the services, evaluation, multiple treatment providers, confidentiality, records, and existing guidelines), and emergencies (procedures and local backup). This project demonstrates that traditional principles of professional ethics can be extended to online services, that comprehensive ethical principles can be developed by groups that cross disciplinary and national boundaries, and that productive collaboration can take place entirely online; and suggest that online clinicians have the potential to regulate themselves.

A developmental model applied to problems of deafness.

From the Editors: This article represents another in our series of "classics" that helped to shape the field of deaf studies and deaf education. The article first appeared as Chapter Two in Sound and Sign: Childhood Deafness and Mental Health, H. S. Schlesinger and K. P. Meadow (1972), Berkeley: University of California Press. The book reported pioneering research and clinical mental health services at the Langley Porter Neuropsychiatric Institute, University of California, San Francisco. For current readers, some of the language may seem out of date, and the Editors have made several minor modifications to ensure that readers fully recognize the original intention of the author. (Such modifications are indicated by square brackets or ellipses for contemporary purposes, but the intentions of the original all have been maintained, and Editors' notes are indicated as such to distinguish them from the Authors' notes.) Nevertheless, many of the ideas are fresh and important. Indeed, some passages serve as particular reminders of significant changes in opportunities for and attitudes about Deaf people over the past three decades. Many of these changes resulted directly from the work of Dr. Schlesinger and her colleagues.

Treatment of Offenders With Mental Disorders

Back to table of contents Previous article Book Forum: Forensic IssuesFull AccessTreatment of Offenders With Mental DisordersC. ROBERT SHOWALTER, M.D., C. ROBERT SHOWALTERSearch for more papers by this author, M.D., Harrisonburg, Va.Published Online:1 May 2000AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This volume is a welcome addition to the forensic mental health literature. As the title suggests, it focuses on mental health treatments for the mentally ill offender in contrast to the more frequently appearing forensic works addressing the issues involved in the various types of preadjudication or presentencing mental health assessments provided by forensic specialists. The number of convicted offenders in the United States increases each year. The publication of a book devoted to treatment issues involving the mentally disordered offender population is timely inasmuch as the correctional population increased more than two and one-half times from 1980 to 1993. Eight percent to 19% of prisoners have substantial psychiatric or functional disabilities, and another 15% to 20% will require some form of psychiatric intervention during their period of incarceration (1).This collection of essays is well arranged, beginning with a discussion of the administrative aspects of treatment programs for offenders with mental disorders, a discussion both thoughtful and practical, which carefully counterbalances the dual mandates to provide treatment to the mentally disordered offender while ensuring adequate custodial safeguards to protect the public. This is followed by a succinct summary of the legal aspects of treating mentally disordered offenders, beginning with a survey of the evolution of the law relevant to the treatment of mentally disordered offenders in the time before the civil rights movement and extending through the civil rights movement to the 1980s and 1990s, a period during which fundamental decisions affecting the rights of offenders substantially revised some of the legal mandates of the civil rights era. The survey concludes with a review of the current state of evolving mental health law, which is seen as incorporating subtle but important changes that will have an impact on the mental health treatment of mentally disordered offenders. Three chapters follow that discuss the specific and sometimes unique problems associated with the delivery of mental health services for the mentally disordered offender in the three primary venues where treatment is most likely to be provided: community-based programs, inpatient facilities, and jails and prisons. The volume is completed with discussions of specialized treatment issues and protocols that apply specifically to three groups of emotionally vulnerable offenders who may require mental health interventions and treatment: sexual offenders, mentally retarded offenders, and juvenile offenders.Although there is no general editorial comment outlining the overall design or any intended unifying themes for each chapter in this volume, several general (and useful) patterns are generally noted as components of each chapter. First, each chapter recognizes, in ways appropriate to the subject matter discussed, the challenges of the unique contexts and constraints within which mental health services are provided to offenders. Also addressed are the unavoidable tensions that are inherent in the dual mandate to provide mental health services to mentally disordered offenders (some of whom are treatment resistant) and at the same time ensure the security and protection that the public demands. Second, each clinically oriented chapter contains a cogent summary of the available research and clinical data pertinent to the subject. Third, the chapters are written in a straightforward and practical manner that facilitates application of the research and clinical data presented to the development and maintenance of good clinical practice and sound professional judgment standards for the treatment of the mentally disordered offender. Fourth, recognizing that the demand for clinical mental health services to the offender population is increasing and that patterns of service delivery generally are in a state of transition and ongoing change—a phenomenon likely to persist for some time to come—most of the clinically oriented discussions include both conceptual and specific clinically applicable materials that administrators and clinicians alike will find useful in ongoing program development. Fifth, the more treatment-oriented chapters all stress the need for more research in the area of linking together treatment methods and treatment outcomes to increase both the credibility and the efficacy of the mental health services provided.This book (both the text and extensive reference lists at the end of each chapter) can certainly be useful to mental health professionals who provide services to offenders and forensic administrators working in programs in which offenders may require mental health services. It can also be an informative addition to materials developed for use in a wide range of forensic teaching and training programs.Edited by Robert M. Wettstein. New York, Guilford Publications, 1998, 438 pp., $45.00.

Clinical trials versus mental health services research: contributions and connections.

The growing emphasis on using empirical data to guide mental health policy decision making has contributed, in part, to a developing dichotomy along the continuum of research on mental health interventions. At one end of the continuum is research on the efficacy of mental health interventions, traditionally referred to as clinical trials research. The goal of clinical trials research is to determine whether or not a specific intervention can be shown to be efficacious for a specific problem. At the other end of the continuum is research on the implementation and evaluation of mental health interventions, traditionally referred to as mental health services research. The goals of mental health services research are to understand the access to, organization and financing of, and outcomes of mental health interventions. The conceptual, methodological, and measurement features of both types of research are presented and suggestions are offered to bridge the gap between the two paradigms. The purpose of this article is to highlight each discipline's unique contributions to mental health research and, in so doing, facilitate a discussion that fosters scientific integration and collaboration between clinical trials and mental health services investigators.