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General Hospital Psychiatry 32 (2010) 477–483

Efficiency in mental health practice and researchIsabel T. Lagomasino, M.D., M.S.H.S.a,⁎, Douglas F. Zatzick, M.D.b,

David A. Chambers, D.Phil.caDepartment of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, CA 90033, USA

bDepartment of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98104, USAcDivision of Services and Intervention Research, National Institute of Mental Health, Bethesda, MD 20892, USA

Received 4 March 2010; accepted 22 June 2010

Abstract

Limited financial resources, escalating mental health-related costs and opportunities for capitalizing on advances in health informationtechnologies have brought the theme of efficiency to the forefront of mental health services research and clinical practice. In this introductoryarticle to the journal series stemming from the 20th NIMH Mental Health Services Research Conference, we first delineate the need for a newfocus on efficiency in both research and clinical practice. Second, we provide preliminary definitions of efficiency for the field and discussissues related to measurement. Finally, we explore the interface between efficiency in mental health services research and practice and theNIMH strategic objectives of developing improved interventions for diverse populations and enhancing the public health impact of research.Case examples illustrate how perspectives from dissemination and implementation research may be used to maximize efficiencies in thedevelopment and implementation of new service delivery models. Allowing findings from the dissemination and implementation field topermeate and inform clinical practice and research may facilitate more efficient development of interventions and enhance the public healthimpact of research.© 2010 Elsevier Inc. All rights reserved.

Keywords: Efficiency; Mental health; Health services research; Intervention development; Implementation

1. Introduction

In its 2001 landmark report, “Crossing the QualityChasm: A New Health System for the 21st Century,” theInstitute of Medicine (IOM) challenged the nation to developa quality 21st century health care system by achieving sixkey aims [1]. Although initial progress has arguably beenmade toward defining and attending to five of these aims inboth general and mental health — safety, effectiveness,patient-centeredness, timeliness, and equity— the sixth aim,efficiency, has remained largely unaddressed, especiallywithin the realm of mental health services.

In July of 2009, the National Institute of Mental Health(NIMH) focused its 20th Mental Health Services ResearchConference on the theme of “Increasing the Efficiency ofResearch and Mental Health Services Delivery.” The

⁎ Corresponding author. Tel.: +1 323 442 4046; fax: +1 323 442 4004.E-mail address: lagomasi@usc.edu (I.T. Lagomasino).

0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2010.06.005

conference convened academic and community researchersand representatives to review progress in mental healthservices research and to advance the field by strategizingabout ways to emphasize efficiency both in future researchefforts and in how research informs clinical practice.

2. Why focus on efficiency?

Why did the NIMH choose to focus on efficiency at thecurrent time, rather than on other key aims? First, althoughthe cost of doing research, as measured by the BiomedicalResearch and Development Price Index (BRDPI), has beenincreasing at approximately 3% per year since 2003, theNIMH budget has experienced smaller increases — or evena decline — in its operating budget since 2004, resulting indeclining purchase power [2]. In 1998, the average yearlycost of an NIMH research project grant was $234,000, whilein 2007 it was $349,000 — an almost 50% increase in lessthan 10 years [3]. Clearly, if research is to continue

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informing science and practice, methods to increase efficientuse of scarce resources are critical.

The second reason for focusing on efficiency is thatdespite the skyrocketing costs of mental illness and growingexpenditures on mental health care, clinical practices have,on the whole, been largely unable to demonstrate improvedoutcomes or cost savings. From 1992 to 2002, health careexpenditures for serious mental disorders increased fromapproximately $63 billion to $100 billion [4]. Despite thissignificant increase, costs from loss of earnings due toserious mental illness rose from $77 billion to $193 billionduring the same time period, and disability-related costsfrom social security and disability income rose from $16billion to $24 billion [4]. Faced with insurmountableexpenditures, state mental health agencies have sometimesneeded to cut even the most basic services.

Third, focusing on efficiency allows us to capitalize onthe many rapid advances in health information technolo-gies in order to improve the ways in which research isconducted and mental health services are delivered. Newlyaccessible, highly applicable technologies permit thetracking and sharing of data from clinical and communitysettings in real time; the ability to use synchronous orasynchronous communication to provide quality care forthose who would otherwise lack access; and the develop-ment of interventions using novel platforms (e.g., homecomputers, smartphones, social network sites). Thesetechnologies may permit efficiencies in research andpractice not previously imaginable.

Mental health services research must play a critical role ininforming the most efficient use of resources. Research canlead to the development and implementation of new andeffective clinical practices; knowledge regarding which keyintervention components have the greatest impact; andpolicy changes that promote the financing and implementa-tion of evidence-based practices. Unfortunately, however, itmay take up to 17 years for research findings to impact real-world settings [5]. Thus, the challenge for mental healthservices research is threefold: it must be conducted moreefficiently, it should inform the development and imple-mentation of effective clinical practices, and its findingsshould be more efficiently translated into clinical practiceand health policy.

In addressing this threefold challenge, we need to beaware of existing incentives and attitudes that may preventan emphasis on efficiency in research and practice. In theconduct of research, for example, rather than finding ways toproduce the maximum amount of information quickly at lowcost, investigators may feel incentivized to budget projectsfor the maximum time and dollars allowable. In clinicalpractice, misaligned financial incentives for providers andhealth care systems may lead to waste. In translationalresearch, although comparative effectiveness research pro-mises to provide important information regarding the relativevalue of interventions, fears about the possible rationing ofcare have often led to the omission of cost comparisons.

Many may be concerned that emphasizing efficiency willcompromise other key health care aims— such as equity—as researchers and practitioners aim to achieve the greatestimprovements quickly and at least cost rather than reach outto those populations in most need. Clearly, we will need toaddress attitudes and realign incentives in order to focus onefficiency.

A focus on efficiency is consistent with the NIMHStrategic Plan from 2008 [6]. In order to transform ourunderstanding and treatment of mental illnesses, the NIMHidentified four overarching objectives, two of which areparticularly relevant to the themes of the NIMH conferenceand this article. The third strategic objective calls for thedevelopment of new and improved interventions thatincorporate the diverse needs and circumstances of peoplewith mental illnesses. As we strive to accomplish thisobjective, we can employ what we have learned from ourexperience with the different — and typically successive —stages of model development, intervention testing, real-worldimplementation, and policy development to move fromintervention development to implementation and uptakemore quickly and efficiently. In an ensuing article in thisseries, Katon et al. summarize their experience with thedevelopment and implementation of the collaborative caremodel; lessons learned may help us to maximize theefficiency of new intervention development. The fourthNIMH strategic objective calls for strengthening the publichealth impact of research. Epidemiologic data, disseminationand implementation experiences, and policy perspectives canbe used to inform the efficient development and implemen-tation of interventions with broad public reach. In this articleseries, Kolko et al. discuss their experiences in developinginterventions responsive to trauma, in settings as diverse asschools and military theaters.

3. Toward a construct of efficiency

The IOM defined efficiency as reducing waste in healthcare and thus reducing total costs [1]. This is in keeping withthe IOM's call to improve the quality of health care byaddressing overuse, misuse, and underuse of medicalservices. Although underuse of needed services mayarguably be the critical priority area in mental health,overuse or misuse of diagnostic procedures or treatmentsmay incur waste and unnecessary costs. For example, in thearea of depression in primary care settings, overuse mayoccur if extensive diagnostic testing is ordered for medicallyunexplained symptoms that are part of depression; misusemay occur if antidepressants are prescribed for patients whohave minor depression or adjustment disorders [7].

Health economists' definitions of efficiency have beensomewhat more specific, relating efficiency to the use ofhealth care resources in such a way as to get the bestvalue for money spent [8]. In their thorough review,McGlynn et al. [9] defined efficiency as the relationship

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between a specific product or output of the health caresystem and the resources or inputs used to create theproduct (see Fig. 1). Achieving efficiency involvesmaximizing output for a given cost or minimizing costfor a given output.

Before proceeding further, it is important to note thatperspective is critical to consider in definitions of efficiency.Different stakeholders — including consumers/patients,providers (physicians, hospitals), intermediaries (healthplans, employers) and society as a whole — each control aparticular set of resources, or inputs, and may seek to obtainor deliver a different set of products [9]. What is efficient toan individual patient may differ from what is efficient to aspecific provider or third-party payor. For example, a patientreceiving medication and psychotherapy may find it mostefficient to see the same physician provider for bothtreatments because of reduced time costs, while his or herthird-party payor may not, given higher fees associated withphysician time relative to other mental health care providers.A physician conducting dementia evaluations may find itmost efficient to obtain laboratory and neuroimaging studieson all new patients prior to meeting with them in order toimprove diagnostic accuracy and timeliness at the first visit,while third-party payors may prefer more targeted diagnostictesting, given the cost of extensive studies and the often lowlikelihood of pertinent findings. General health careproviders may not find it efficient to care for mental healthproblems if such services are not incentivized; however,from a societal perspective, early diagnosis and treatment ofmental disorders in general health care settings may producesavings in unemployment and in other service sector costs.Research funding agencies may value efficiencies in theresearch process itself (e.g., use of existing informationsystems or practice research networks, streamlining of

Fig. 1. Efficiency defined as the relationship of o

recruitment procedures, incorporation of multiple analyses);in the development of new interventions (e.g., informed andefficient intervention development, capacity for real-worldimplementation and sustainability); and in potential impacton public health and policy.

4. Outputs and inputs in mental health servicesand research

If efficiency involves maximizing the relationship ofoutputs to inputs, or resources to outcomes, how areoutputs and inputs defined in relationship to mental healthservices? Outputs may include both health services andhealth outcomes; in fact, health services are an interme-diate output that results in specific health outcomes [9].Measures of mental health services may include thenumbers of persons served or the number of service visits,psychoeducation sessions, prescribed medications, psycho-therapy sessions or evidence-based components provided.It is important to note that outputs may be measured for asingle visit, for variably defined time periods, or fordiscrete episodes of care. For example, prescriptions maybe measured for single visits, for yearly periods, or for anacute illness episode. Research-related outputs may includethe development of interventions that are easily adapted bydiverse end-users or that have capacity for disseminationand sustainability.

Ultimately, health outcomes may be a more pertinentoutput to measure, despite the fact that they are impacted notonly by health services received but also by a multitude ofother factors, including patient characteristics. Diverseoutcomes may be disease-specific or include quality of life,patient satisfaction, employment, or academic performance.

utputs to inputs. (Adapted from Ref. [9].)

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From a societal or funding agency perspective, outcomesmay also include concerns such as building researchinfrastructure and community capacity, reducing disparitiesfor ethnic minorities, and having policy impact.

Similar to outputs, inputs may include both physicalresources and financial costs; physical resources are anintermediary input that result in financial costs [9]. Physicalresources required to deliver mental health services andimprove outcomes may include clinical and administrativepersonnel time, with attention to the most efficient mix ofneeded personnel. Provider mix includes not only mentalhealth professionals but also general practitioners, consu-mers, and families. Physical resources also include medicalequipment, supplies, and information systems. From aresearch funding agency perspective, resource considera-tions include investigator time and the potential need todevelop health information systems, research infrastructure,and community partnerships.

Ultimately, physical resources, including personnel time,can be converted to costs. Doing so allows for importantcomparisons to be made across treatment interventions orresearch projects. As depicted in Fig. 1, the ratio of healthservices or health outcomes to specific costs may eventuallybe calculated as a measure of efficiency. Notably, althoughinputs for the most part may be reducible to costs, outputsfrom certain treatments, interventions, or research studiesmay be quite varied and not as easily reduced. Anintervention may improve clinical and employment out-comes while reducing disparities; a research study maydevelop academic and community infrastructure whilehaving important policy impact. Although efficiency maybe calculated separately for each outcome, methods are beingdeveloped in other health care sectors to incorporate multipleoutputs [9].

5. Three types of efficiency

Three types of efficiency have been broadly defined [10].Technical efficiency is achieved when the maximum outputis produced for a given set of physical resources (output/physical resources) or when a given output is produced usingfewer resources. If an individual aspect of a multifacetedintervention is almost entirely responsible for improvingoutcomes, it is more technically efficient to provide theindividual intervention component. If a proposed study canproduce valuable knowledge using existing data systems andinfrastructure, it is more technically efficient than oneneeding to develop these resources anew.

Productive efficiency is achieved when the maximumoutput is produced for a given cost (output/costs) or when agiven outcome is produced for the same cost. Rather thanusing physical resources as the measure of input, resourcesare translated into costs, allowing comparisons to be made.For example, for similar improvement in depressive severity,one might calculate the costs of providing antidepressant

treatment or psychotherapy; the less costly treatment wouldhave greater productive efficiency. Alternatively, for a givenresearch cost, a study producing information on effectivenessand implementation would have more productive efficiencythan another focusing on only one set of outcomes.

Critical to the current health care debate, allocativeefficiency refers to maximizing societal good with a given setof resources. The goal is to maximize community welfare;the output is not only improved health outcomes, but howthese outcomes are distributed across society. When strictlyinterpreted, allocative efficiency is only achieved whenallocating resources any differently would make at least oneperson worse off. However, because this would precludechanges that would make many people much better off at theexpense of making a few people a bit worse off, thedefinition of allocative efficiency has been adapted so as todescribe a state in which resources — in this case both forresearch and for clinical practice — are allocated in such away as to maximize community welfare [10].

How do technical, productive and allocative efficiencyrelate to one another? As described by Palmer and Torgeson[10], an intervention with allocative efficiency is usuallyproductively efficient, and one with productive efficiency isusually technically efficient. The inverse of these relation-ships is not necessarily true, however. For example,productively efficient interventions that disproportionatelyimpact a segment of the population may deepen disparitiesand defy allocative efficiency. Especially in environmentswith few resources, technically efficient interventions thatmake the best use of what is available may not beproductively efficient.

6. How can we measure efficiency?

As we develop a focus on efficiency in mental health carepractice and research, it will be critical to advance ourmeasurement capacity in this area. Efficiency can only bemaximized if it can be assessed and tracked. In theirthorough review, Hussey et al. [11] conclude that noconsensus set of health care efficiency measures currentlyexists. In addition, those measures that do exist havesignificant limitations [11]. First, measures that are used inreal-world settings and those that have been scientificallystudied and validated diverge widely. Measures in commonuse have typically not undergone validation studies. Second,existing measures have mostly taken the vantage point of thepayor or employer and focused on the efficiency of hospitalsor providers. Provider, consumer and societal perspectiveshave not been widely represented, nor has that of researchfunding agencies. Third, current measures typically fail toaccount for the quality of specific services; they may focuson the quantity of services provided or on the number ofpatients served, without incorporating a measure of thequality of services rendered. Thus, a system design thatresults in more patients being served in less time might be

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considered more efficient than one delivering higher qualityservices to somewhat fewer persons. Finally, most existingmeasures are resource and time-intensive, and thus do notlend themselves easily to guiding system improvements inreal time.

Advancing the field of efficiency in mental healthservices practice and research will thus require thedevelopment of valid and useful measures. These will needto capture those inputs and outputs that are most important todifferent stakeholders and incorporate concern for quality.Measures will need to be reliable and reproducible; feasiblein relation to burden and cost; and actionable so as to be usedin real time to impact practice. Measurements should enablethe comparison of different treatments, interventions, orsystem designs in order to enable stakeholders to makemeaningful choices regarding mental health care practices.

7. Integration of the efficiency theme with the NIMHStrategic Plan Objectives

How can efficiency be achieved in the development ofmental health interventions and in services research? Wepreviously underscored the threefold need to more efficientlyconduct research; develop and implement effective clinicalpractices; and translate research findings into clinicalpractice and health policy. Typically, however, as depictedin Fig. 2, intervention research proceeds along a fairly linearcontinuum of basic research, efficacy trials, effectivenessstudies, and widespread dissemination [12–14]. However,starting with the ultimate goal in mind — dissemination —may lead to greater efficiency along this continuum. An earlyunderstanding of contextual factors - relating to patients,providers, organizations, and communities— that will likelyinfluence successful dissemination can promote the devel-opment of those interventions most likely to be implementedand have public impact. Rather than spend significant

Fig. 2. Stages of intervention research and potential feedback from disseminadevelopment. (Adapted from Refs. [12] and [14].)

resources to develop and test treatments that may eventuallybe difficult to implement and disseminate, efficiency may beachieved when considerations related to the widespreaddissemination of an intervention permeate the process ratherthan being confined to final stages. These points arehighlighted in the following case study.

8. How clinical epidemiologic data from real-worldpractice settings can inform efficiencies in thedevelopment of small molecules targeting thesecondary prevention of PTSD

A 25-year-old Marine in Iraq suffers from multiplelumbar and left lower extremity fractures when his Humveehits an explosive device. Over the course of 3–4 months, heis transferred from Bagdad, Iraq, to Lansuthl, Germany, toWalter Reed Hospital in Washington, DC, and, finally, to anArmy Medical Center on the West Coast of the UnitedStates. After being told that his left foot will need to beamputated, he requests a second opinion and is transferred toan urban level I trauma center, where he is seen by thepsychiatry consultation service due to symptoms of pain,anxiety, and depression.

What evidence-based treatment exists for this man, andwhere and when might it be delivered, given his multiplemedical treatment sites over the course of several months?In its evidence-based review of treatments for PTSD, theIOM [15] strongly endorses cognitive-behavioral therapy;however, this treatment is very difficult to deliver acrossmultiple, acute medical settings in the early phases of post-injury care. As demonstrated by this case study, we havean urgent need to reach persons who are currentlysuffering by expediently and efficiently developingempirically supported treatments that can be feasiblydelivered in unique posttraumatic contexts such as acutecare medical settings.

tion and implementation research to inform early stages of intervention

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In a recent review article, NIMH Director Dr. ThomasInsel outlined the stages of intervention development for newpharmacologic treatments, commencing with the basicscientific development of small molecules and ending withclinical trials and eventually widespread implementation[13]. For the secondary prevention of PTSD, a theoreticalrationale has been provided for exploring the use of a diversegroup of candidate compounds, including corticosteroids,beta-adrenergic antagonists and opiate analgesics. Corticos-teroids and beta-adrenergic antagonists have both beenrecently selected for initial efficacy trials. However, usingreadily available, inexpensive data from population-basedtrauma registry information systems, Zatzick and Roy-Byrne[16] found that at the time of hospital discharge frominpatient settings, 80–90% of trauma survivors werereceiving opiate analgesics and 30–45% were receivingnonopiate analgesics, in contrast to less than 5–10%receiving corticosteroids and beta-adrenergic antagonists.

This pharmacoepidemiologic study underscores theubiquitous use of analgesic medication in acute care settingsand is consistent with population-based phenomenologicalstudies suggesting that patients' primary concerns in the daysand weeks following traumatic injury are physical pain andbodily integrity [17]. A recent investigation found that opiateadministration in wounded combat veterans may decreaselater PTSD symptoms [18]. These clinical epidemiologicstudies suggest that initial efficacy trials should includeanalgesics for the prevention of secondary PTSD; resultsmight also stimulate basic research on compounds targetingboth pain and anxiety. As depicted in Fig. 2, this exampledemonstrates how population-based data from real-worldpractice settings— from contexts in which treatments will bedisseminated— can inform the early stages and efficiency oftreatment development.

Similarly, dissemination and policy experiences fromdisparate fields can feed back to inform basic investigationsand intervention development in mental health services. Atthe NIMH conference, Roy Cameron, Ph.D., from the Centrefor Behavioral Research and Program Evaluation (CBPRE)demonstrated how evaluation findings from adolescenttobacco-related programs conducted in Canadian schoolsinformed the development and implementation of futurepopulation level programs. Working together closely,interdisciplinary teams of social actors, researchers andpolicymakers can inform program development through aprocess of intervention implementation, evaluation, andprogram and policy revisions based on findings. Field andresearch experiences with dissemination and implementationfacilitate the more efficient development of interventions fordiverse populations while also enhancing the public healthimpact of mental health research and services delivery.

9. Introduction to journal series

The plenary sessions of the 20th NIMH Mental HealthServices Research Conference convened researchers, practi-

tioners, and policymakers to discuss how to maximizeefficiencies in the development and implementation ofservice delivery models and in response to public healthchallenges. The following articles in this series present thehighlights of those sessions, with implications for futuredevelopments in mental health services research and practice.

The first, by Katon et al., describes the development,testing, implementation, and policy implications for thecollaborative care model for depression. Lessons learnedfrom different stages in this process suggest opportunitiesfor further efficiencies in mental health service deliveryand research.

The second, by Kolko et al., discusses emergentresearch on the impact of trauma on the mental health ofthe US population. Drawing from work on interventionsfor children and adolescents and from studies in responseto large-scale traumatic events (e.g., terrorism, hurricanes),authors present ways in which research can maximallybenefit public mental health.

Finally, the series includes two commentaries from theleadership of NIMH and from the journal editor. The formercontextualizes the theme of efficiency within the mission ofthe institute and its recent strategic plan, while the latterapplies the theme to the journal's mandate.

10. Conclusion

Limited financial resources, rising costs for both mentalhealth research and clinical practice, and the development ofnew technologies have spurred a new emphasis onefficiency, one of the six key aims specified by the IOMfor developing a quality mental health system [1]. Defini-tions of efficiency in mental health research and clinicalpractice are still in preliminary stages, and measurements arein need of further development. Findings from disseminationand implementation studies may facilitate efficiencies inintervention development. By ensuring that available dollarsfor research and mental health service delivery are mosteffectively and efficiently spent, scientific discoveries andimprovements in technology and field capacity can signif-icantly alter the trajectories of those with mental disordersand improve our response to the tremendous public mentalhealth need within our society.

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