Focused on the treatment of depression, the first 2 years of our IP-RISP grant were devoted to (1) developing a working and sustainable research partnership and (2) building capacity for, and reducing barriers to, recruitment and research participation. In this paper, we have delineated the challenges faced and the strategies implemented to meet each of these goals. We identified central strategies and challenges through interviews, review of grant materials and minutes from development meetings, and informal discussions with clinicians, administrators, staff, and research personnel collaborating on the IP-RISP.

The NHSP and Penn have been equal partners in the development of the research agenda, budget, and proposals for funding. Core members of the IP-RISP partnership include NHS’s regional director of practice development, directors of outpatient services, intake directors, an NHSP director, a clinician, 4 Penn researchers, and 2 support staff. Additional individuals from a variety of positions and perspectives have participated in our planning meetings, on the advisory board, and on subcommittees. Decisions regarding research topics, study design, and implementation are made through consensus. For example, in identifying major depressive disorder as the central focus of the grant, we considered common consumer diagnoses, NHSP’s interest in new assessment and treatment procedures, and researchers’ backgrounds.

Because a partnership of this nature requires a bidirectional flow of information and ideas, we sought opportunities for direct contact between the core IP-RISP partners and a broad group of NHSP personnel and consumers. Although an NHSP clinician has served on the executive committee since the partnership began, additional clinician involvement and input has been essential given the large number of clinicians at NHSP. Because of the size of NHSP, busy clinical schedules, and clinician turnover, a variety of measures have been necessary to keep clinicians informed about ongoing projects, solicit their input, and facilitate referrals for ongoing research.⁵ Discussion and formal presentations about research projects and findings have been included in monthly clinical meetings. We also formed ad hoc committees to address specific aspects of upcoming studies, and had informal conversations (e.g., time in between appointments) about IP-RISP initiatives. When recruiting therapists for pilot psychotherapy studies, we place informational flyers in clinicians’ mailboxes, and the outpatient director follows up with discussion of the project at staff meetings. A research assistant (RA) orients new clinicians and staff to the IP-RISP to make them aware of research projects and procedures. Her availability allows clinicians and staff to provide input, share ideas, or ask questions at their convenience. To date, clinicians have contributed to and played a role in IP-RISP activities as standing members of the advisory board, through one-time participation in ad hoc advisory meetings, by making suggestions, responding to surveys, referring clients, serving as study therapists, and collaborating on research projects.

Recruitment of consumer members to the advisory board has been challenging. Calls for consumer participation have been made through the quarterly newsletter that is distributed throughout the agency, signs in the waiting rooms, and clinician outreach to their consumers. Despite offers to compensate consumers for their time and transportation, volunteers have not been forthcoming. Some potentially interested consumers were not able to commit to longer term involvement because of practical considerations such as childcare, work, or family obligations. Many depressed consumers who seek treatment for depression do not continue in longer term treatment,⁶ and others struggle with symptoms such as lack of motivation or levels of impairment that limit their ability to make a commitment to the IP-RISP. The IR-RISP studies have focused on consumers who typically attend therapy once a week, and the level of engagement and investment in the agency may be lower among this consumer population than among consumers who participate in more intensive outpatient programs. Some consumers who were identified as potential advisory committee members were clients of clinicians who served on the IP-RISP committees. Thus, their participation would have introduced additional challenges related to dual relationships. In sum, these obstacles made it difficult to receive input from a standing committee of representative consumers.

As we sought consumer collaborators, other more familiar and accessible approaches to solicit consumer input were needed. We have tried to find ways to solicit suggestions and feedback in ways that require less of a commitment on the part of the consumer and that have been outside the scope of formal research projects. For instance, consumers have been willing and able to meet with us for one-time discussions, even if they could not commit to longer term involvement. During the design phase of some studies associated with the IP-RISP, we discussed ideas and procedures with consumers to assess interest, satisfaction with the proposed study, or the “user friendliness” of the procedures. We have also sought their opinions and feedback within the context of research projects. Over time, as a result of this contact with consumers, we have noticed increased communication between IP-RISP personnel and consumers. Now that the IP-RISP activities and personnel are more familiar, consumers have started to recognize us, share ideas, and express interest in research activities.

One of our earliest successes in the development of our research capacity illustrates the importance of listening to and learning from each other. In discussing several ideas for research on depression, NHSP personnel raised concerns about their feasibility given the extremely high rates of disengagement from services after a single intake session as well as high dropout from treatment. We were all concerned about factors that led to disengagement and the implications of attrition on treatment effectiveness, staff morale, and the interpretability of research findings. We examined agency data to document the extent of the problem, talked with consumers, and conducted an extensive literature review.⁸ When we sought feedback from consumers at one site, we learned that the physical environment of the waiting area was a reason that consumers did not return for treatment after an intake. Based on what we learned, our first joint research project focused on renovating and refurbishing the waiting area and treatment offices and to study the impact of these improvements. Our hope was that consumers would feel more comfortable and be more likely to return for appointments. The renovations indeed resulted in greater satisfaction from agency staff and consumers,⁹ and attendance at the first treatment session after intake increased. This project is an example of how working together to develop projects resulted in benefits for multiple stakeholders: Consumer satisfaction, attendance, and staff morale improved, and our capacity to recruit and retain participants in future research may also have increased.

Another issue related to high rates of attrition is the fee-for-service payment model, which many of the city’s agencies, including NHSP, use to pay their therapists to minimize financial losses that occur when patients “no show” for scheduled appointments. This model can impact the clinicians’ ability to participate in research-related activities. If research screening and recruitment add significantly to the time spent with each client, clinicians can see fewer clients each day. Using an iterative process involving feedback from staff and clinicians who perceived initial strategies as too time consuming, we developed a feasible and accepted strategy. Consumers are now given a very brief screening form to complete when they check in. The completed form is given to the intake clinician at the start of the evaluation, where it is reviewed and scored to determine study eligibility. The clinician introduces eligible clients to an RA at the end of the intake so that the client can learn about opportunities to participate in research and ask questions. The amount of time these steps require of clinicians is typically 5 minutes or less. Periodic reminders and trainings in screening procedures have been important to the success of this effort. The steps we have taken to refine our screening and recruitment procedures have decreased the number of incorrectly scored screening forms by 35%, and increased our ability to identify potential research participants.