My ultimate goal is to become a leading expert in the design, implementation, and evaluation of novel therapeutic and preventative interventions for patients receiving care in the psychiatric emergency service (PES), which for many is the primary entrance point to the mental health care system. Viewing the PES as an alternative portal of entry provides a compelling opportunity to rethink how we provide mental health services to underserved, highly distressed patient populations at elevated risk of morbidity and mortality, and to extend our understanding of how best to deploy the costly resources of the PES. During the K23 award period, I will build my patient-oriented, research, evaluation and system-oriented intervention skills with a specific goal in mind. By the end of this award period, I hope to be well prepared in all academic, administrative, and methodological skill areas needed to carry out the highest quality randomized controlled trials in the most challenging patient populations imaginable. The project that I am proposing for this application will have two related parts. First, using population-level profiles of those patients at highest risk for treatment noncompliance, I will implement and test a model intervention aimed at non-hospitalized suicidal patients, discharged from the PES, who are at highest risk of not sustaining prescribed outpatient care. For the most part, these patients now are 'lost to care' until they reappear at the PES door for another transient contact. The proposed randomized prospective trial will compare two alternative approaches to linking discharged PES patients to outpatient mental health services: treatment as usual (provision of an outpatient intake appointment within five days of PES discharge) versus a home or community mobile crisis team (MCT) visit within 48 hours. The content of all initial clinical contacts will be standardized. In the second part of the proposed project, I plan to examine the implications of interventions both from the patients' perspective (using symptom and functional measures), and from a health services perspective (through mental health service usage data). By the end of this Career Development Award period, I will be highly prepared to implement and rigorously examine large-scale PES-based clinical interventions to reduce morbidity and mortality for disenfranchised patient populations. This preparation will facilitate future R01 level studies, applying skills gained during the K23 award period to conduct trials focused on children and youth, elders, ethnic and cultural minorities, substance abusers, personality disordered patients, and possibly other groups receiving care in the emergency treatment setting.
