A Lancet Psychiatry commission with global membership, led by Dr. Beth McGinty, chief of the Division of Health Policy and Economics and the Livingston Farrand Professor of Population Health Sciences at Weill Cornell Medicine, and Dr. Matthew Eisenberg, an associate professor of health policy and management and mental health at the Johns Hopkins Bloomberg School of Public Health, presents strategies for conducting research to help narrow the mental health implementation gap.
Worldwide, there is a significant gap between research on effective ways to improve mental health and implementation, or the ability to provide interventions to people who need them. Research demonstrates many approaches that can promote mental health and prevent and treat mental illness. However, most people who could benefit never receive these interventions, which include clinical mental health treatments, school-based prevention programs, policies that address social determinants of mental health like adverse childhood experiences, and more. Implementation research aims to produce the evidence needed to overcome the gap between effective treatment and treatment that reaches people in need, but sometimes falls short. This commission recommends transformations to mental health implementation research to produce more actionable evidence.
“The traditional research-to-implementation process does not consider real-world implementation until very late in the game,” Dr. McGinty said. “Our commission calls for an integrated research-implementation model, where implementers such as policymakers, system leaders and clinicians work with researchers across all phases of the research process to develop and test interventions that are successful and scalable to those who need them.”
Poor mental health and lack of access to effective interventions are concentrated among marginalized groups, including those experiencing poverty, discrimination, trauma and other factors. The COVID-19 pandemic exacerbated these inequities through political, economic and social stressors. The commission emphasizes that equity must be a central goal of mental health implementation research.
“Our commission calls for centering health equity in mental health interventions and implementation research by building and sustaining equal partnerships between researchers and communities experiencing mental health inequities,” said Dr. Lola Kola, commission member from the University of Ibadan in Nigeria. “It is critical that we prioritize strategies that emerge from within communities experiencing inequities, rather than imposing ‘top-down’ approaches.”
A host of political, cultural, policy, system, community, provider and individual-level realities influence whether and how different approaches can be implemented across settings. Too often, research produces interventions that can improve mental health in tightly controlled research settings but are difficult or impossible to implement in the real world.
“We need to reconsider traditional approaches that test interventions in efficacy and effectiveness trials but fail to consider implementation at the start of trials or are not co-designed with key constituents,” said Dr. Rinad Beidas, commission member from Northwestern University. Dr. Beidas adds that the field should test psychosocial interventions in the context of delivery, in partnership with key constituents, and with hybrid approaches that study both effectiveness and implementation, potentially with hybrid implementation-effectiveness designs.
Per Dr. Rahul Shidhaye, commission author from the Pravara Institute of Medical Sciences University in India, research approaches should expand beyond traditional randomized controlled trials. “Additional approaches, including nonexperimental approaches for causal inference, systems science and mixed-methods research play a critical role in studying strategies to overcome the mental health implementation gap.”
The commission addresses each of these problems and provides the following solutions: (1) integrate research and real-world implementation; (2) center equity in mental health intervention and implementation research; (3) apply a complexity science lens to mental health research; (4) expand designs beyond the randomized clinical trial (RCT), including embracing rigorous nonexperimental approaches; and (5) value transdisciplinarity across endeavors.
“These recommendations are drawn from our commission’s 18-month long process, which included multiple commission and working group meetings and extensive review of mental health implementation research literature," said Dr. Nathalie Moise, commission author from Columbia University. “Our commission’s recommendations draw upon members’ collective experiences in mental health research, policy and practice. We look forward to engaging with the mental health and implementation research communities to apply and refine these recommendations in the future.”
The commission further emphasizes the roles of policy, economics and systems in scaling mental health interventions. “Mental health implementation has frequently ignored these critical areas, focusing instead on provider- and individual-level approaches,” notes Dr. Eisenberg. “We need a transdisciplinary approach that includes researchers and implementers with expertise in policy, politics and systems.”
These recommendations are intended to comprise a first step in improving mental health implementation research. The commission highlights the need for a global mental health implementation research network to apply, evaluate and refine its recommendations.
“Mental health implementation research has typically been concentrated in high-income countries. Moving forward, expanding research led by researchers and community partners in low and middle-income countries is a huge priority,” Dr. McGinty said. “We have a lot of work to do.”
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