Commentary: Service system perspectives on early intervention research.

As a representative of a Government agency that funds mental health services and that has a role in shaping and funding policy initiatives in the United States, few areas of schizophrenia research are as exciting to me as the prospects engendered by the studies on early intervention described in this special issue. In recent years, the concept of recovery from serious mental illnesses promoted by consumers of the public mental health system has gained increasing acceptance (Jacobson and Curtis 2000; President's New Freedom Commission on Mental Health 2003). The notion that recovery is possible is providing hope to consumers, family members, and service providers with regard to outcomes for people with serious mental illnesses, including schizophrenia. Despite the new optimistic outlook and progress in the development of effective services for people with serious mental illnesses, however, severe and persistent mental illnesses remain debilitating for many people (Murray and Lopez 1996). The U.S. public mental health system primarily provides services to people with the most severe and persistent mental illnesses who are largely disabled by their illnesses (Federal Register 1993; Larson et al. 1998). Whether the research described in this special issue focuses on primary, secondary, tertiary, population, universal, selective, or indicated prevention, or the high-risk, vulnerability, preonset, premorbid, earlyor late-prodromal, first episode, or early post-onset stages of the illness, the promise of this new line of inquiry for the U.S. service system lies in the possibility of reducing the number of people for whom mental illnesses will become persistent and disabling. The final report of the President's New Freedom Commission on Mental Health (2003) describes a growing frustration with the length of time required for new practices to be incorporated, on a widespread basis, into the U.S. service system after they have been proven effective. Many reasons for this lag have been identified (Institute of Medicine Committee on Quality of Health Care in America 2001), and the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) is working, in partnership with the National Institute of Mental Health (NIMH), to reduce the gap through a number of initiatives (McDonel Herr et al. 2003; NIMH Request for Applications No. MH-03-007; SAMHSA Request for Applications SM 03-003; U.S. Department of Health and Human Services 2003). Some of the barriers to implementation of evidence-based practices, however, may be most effectively overcome by foreseeing and beginning to address them during the earliest stages of research in a new area of intervention. The relative youth of the science of early intervention for schizophrenia offers a golden opportunity for the research and service communities to work together to develop programs that will work "in the real world." By engaging mental health service system stakeholders in the discussion early on, the research can be designed to reflect their concerns, and policy and system changes that will be necessary to support the practice can be set in motion to ready the field for implementation. Considering the service implications of the research presented in this special issue at a relatively early stage of the science suggests steps that could be taken to improve the prospects of translating useful findings into the service system in a timely fashion. Although my perspective is based on my experience with the U.S. mental health system, the insights presented in the paper by McGorry et al. (this issue) suggest that the fundamental issues cross geographic and political boundaries, although their resolution may differ among countries. In the final section, I offer perspectives on Heinssen et al.'s proposal for a multisite approach to research on early serious mental illness (this issue), based on my experience in conducting multisite evaluations sponsored by the SAMHSA Center for Mental Health Services.