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Research Partnership Seeks to
Improve Treatment for Mentally Ill
welve years ago, when Susan Essock joined the staff of Connecticut's Department of Mental Health, she came equipped with a knack for obtaining grant money. Essock's grants, from both the federal government and private foundations, were primarily for the purpose of studying policies and practices to determine which most effectively met the diverse mental health needs of Connecticut residents being served by the department.
Up to that point, the department had done research, often with outsideconsultants, but had no formalized in-house research division. In 1991, Essock made a decision that, a decade later, would have dramatic implications for both her state agency (now called the Department of Mental Health and Addiction Services, or DMHAS) and the University of Connecticut. Uncovering more and more funding for mental health policy research, she decided to subcontract with UConn, develop a collegial relationship with the faculty, and employ UConn psychology graduate students to assist with much of the research.
From the outset, the relationship was a productive one. Initially affiliated with the A.J. Pappanikou Center on Special Education and Rehabilitation, Essock, a psychologist, found herself gravitating toward UConn's Department of Psychology, and in 1998 she moved the state contract there.
The most visible result of this collaboration has been the creation of a dedicated research division at DMHAS that has grown to more than 20 staff, all of whom are UConn employees.
The collaboration also has striking benefits for both UConn and DMHAS. The research division Essock founded has a dependable staff of top researchers and highly trained graduate students to assist with its ever-expanding slate of research projects. And UConn benefits from a significant infusion of funding, and exceptional education and training opportunities for graduate students.
The division's research concerning clozapine presents an excellent example. Introduced in 1990, clozapine was the first new anti-psychotic drug since the 1960s, and its arrival was accompanied by great fanfare within the psychology community. In tackling the debilitating consequences of schizophrenia, it worked better than any other pharmaceutical available.
But there were two decided problems.
First, for a tiny percentage of patients, clozapine was potentially life-threatening. It caused a precipitous decline in white blood cells, called agranulocytosis, and thus patients being treated with the drug had to be monitored very carefully.
From DMHAS' standpoint there was another striking drawback. Clozapine's price tag - $8000 per person per year - seemed to make it a prohibitively expensive therapy for patients in Connecticut's state hospitals.
Essock wasn't convinced, however. Unquestionably, the price was steep, but she also knew that it had to be compared with the long-term cost of housing and caring for patients who seemed to have little likelihood of getting out of the hospitals.
With support from the department's commissioner, she was able to get an allocation of funding from the Connecticut General Assembly for a cost-benefit evaluation of the utility of clozapine in treating long-term state hospital residents. That funding, in turn, led to funding from the National Institute of Mental Health for a companion study with implications for nationwide policy.
Essock's study occupied the research division for most of the next four years, but well before it was concluded, the results had proven what she suspected might be true from the outset. Clozapine was unquestionably expensive, but it was also efficacious, restoring functionality to people who previously had little hope of ever living a normal life. When the cost of "warehousing" those patients was balanced against the cost of clozapine for people who had returned to a level of functionality in society, the drug was shown to pay for itself within two years.
"All of the research we do involves a cost analysis," says Linda Frisman, a research professor in psychology at UConn who took over as research director at DMHAS when Essock accepted a position with the Mount Sinai School of Medicine in New York two years ago.
"We evaluate a wide range of things - procedures, promising therapies. But all of our research has in common an evaluation of effectiveness versus costs."
The research also explores ways to provide better service cost-effectively. In an evaluation of criminal justice diversion programs for people with co-occurring mental health and substance abuse disorders, for instance, the research division examined procedures to identify people with these problems who were being arraigned in Connecticut courts. By identifying them through recommendations and screens of arraignment lists, the division concluded that they could not only play a role in ensuring that these individuals got appropriate care, but could also dramatically reduce jail costs. The division's recommendations will result, this summer, in the introduction of diversion programs in all Connecticut courts where they were not previously in place.
Like Essock, Frisman has demonstrated a strong ability to attract grant money for the program. In part, she attributes that ability to the role she plays in DMHAS, where she is able to hear about emerging ideas and issues that are crying out for evaluation and match those ideas with available funds. Currently, for instance, the division is studying such disparate issues as the effectiveness of a program run by and for mental health consumers; a study of conventional versus "atypical" psychotropic medication for schizophrenia; an evaluation of a program for homeless mothers with substance abuse disorders; and a comparison of whether homeless mentally ill people do better in regular community apartments with services or clustered apartments with services.
The broad scope of research programs presents exceptional learning and work opportunities for UConn students, many of whom have enthusiastically embraced the program and the opportunities it presents.
"What attracted me to the program," says Nancy Covell, a research associate in psychology who got involved as a graduate student seven years ago, "was the opportunity to work with statistics and methodological evaluation. I saw it as a real opportunity to extend my knowledge beyond what we were doing in graduate school. It turned out to be everything I had hoped for. The work done here is very rigorous, thoughtful and ethical. It also allowed me to expand my contacts with experts in many disciplines across the country."
Amber Douglas, a second-year graduate student in psychology, at UConn, agrees. "We're very fortunate to have this relationship with DMHAS," she says. "Internships in the research division provide tremendous opportunities to engage in sophisticated research and work on projects with multiple sites and challenges. For me, this has been fantastic. It's a really great learning opportunity."