So in the spirit of this, I want this to be conversational in the sense that we're going to be a little light on methods, but more on content and happy to answer any specific questions, but we'll see, I want to keep this for the broad audience and be able to everybody get a little something out of it. But really what I want to focus on is how is a case study and how we take evidence and we translated into action and we translated into scholarly work. And I think this is at least from my career, one of the best examples of where we've been able to do that. So I'll just start briefly, who I am. So I'm a recovering epidemiologist. That was what my training was in, and then I turned to health services research and health policy research. And the transition there is that most of my work uses administrative data to understand health outcomes for program evaluation. And what I mean by administrative data might be Medicaid claims data, it might be enrollment data. It might be data that's collected for non research purposes. And what I'm really interested in is questions that are applicable to population health or public health health policy and health programs. How do we know that what we're doing is making an impact or how can we make recommendations to improve the impact that those programs are having? And what really, I think I care about is vulnerable populations, and that's broadly defined, but that's anybody that could be having an adverse effect from a policy or being left out or somebody who's especially vulnerable to health care or access to health care. I kind of asked the question broadly and feel free to chime in in the chat, many people probably eating lunch and things like that. But what is our goal for research? So that can be like as a research or what is your goal, but it could also be from a general perspective. What is the goal of research more generally? And so I think for me, it's impact. Right? What I want to do is not just publish papers. I do want to do that. I think that's important. I think dsemination of our work is the goal of scholarship and research. But I can't stop there. We need to see action. We want to see the world, you know, we want to impact the world, we want to impact the state, we want to impact our communities and have bring the evidence so that we can do that better and make sure that we're doing all that we can. And that's what really drives me. When I see a paper published, I'm really proud of it. But when I see research and the findings of that paper turned into something where there's a lasting impact. That's what I'm really proud of. And so I think this is ambitious. We don't always do that. I have plenty of papers that, you know, I think maybe only my mom has read. And that's fine. Like, sometimes that happens, but I think that we should always sort of strive to do bigger things and have bigger impact. And so specifically to this project, I'm going to start with a weird beginning, and that's corn. And so Indiana, as you might know, is the leading producer in the United States of corn, like half of Indiana crop land is corn. We produce 20% of the nation's popcorn. In fact, that is Indiana's official snacks popcorn. In 2019, sales of corn or corn revenues from the state was over $3 billion. That was actually a little bit of a down year. Nowadays, it's over four around $5,000,000,000. You're wondering, what does this have to do with mental health or the economic costs of mental health? Well, in 2019, based on the evidence that I'm going to show you, we spent more or we lost more economic value to mental illness that was not treated or inadequately treated than we earned through corn sales. And so putting that in perspective, I think this kind of says like, Okay, you know, if corn is majorly important to the state, so should addressing mental health needs? And so I'll tell you a little bit more about how we know this or how we estimated and came to that conclusion. But first, I want to kind of plug and say with the partnership that enabled this research to happen. So Wis Indiana stands for well being informed by science and evidence in Indiana. And its role is to engage Indiana's experts to evaluate and inform Indiana practices, programs, and policies. This is a partnership with the Through the CTSI, which includes Purdue and Notre Dame and all across the state and the family and Social Services Administration. We tend to get task orders. We're up to about 50 now since it began in 2019. And what we really are trying to do is find the right academic expert to provide the evaluation that can help translate that evidence into the hands of decision makers so that they can improve or make decisions about programs that is within the FSSA, wheelhouse. If you're not familiar with FSSA, it houses many different divisions, mental health and addiction, Office of Medicaid, policy and planning, aging, early childhood, education, and others. And so we have a pretty broad book of business in terms of what kind of programs we're evaluating. Specifically for this project that I'm going to talk about, the Indiana Behavioral Health Commission requested the research. And so the Indiana Behavioral Health Commission was established in 2019, and it was designed or it was actually mandated to make recommendations to improve behavioral mental Health Care in Indiana. And one of the tasks that it was mandated to do was establish the cost of untreated mental illness in Indiana. So that comes directly in the charter for the Indiana Behavioral Health Commission. And so Jay Chery was directed that. He's the director of DMHA, and he was the one that really made the request of Wise to conduct this research. Well, when they asked us this, I kind of thought, I don't really know how to do that because, you know, we could think about, Oh, well, what does it cost? What do we spend in treating mental illness in the state? I could do that. That's pretty straightforward. That's accounting. We could take, we could take claims data, we could estimate that. That wasn't what they were asking. We could also think about, what are the consequences of untreated mental illness? Like we know from literature, it can be a risk factor for homelessness or there can be poor quality of life or it can leave the encounters with the criminal justice system. It could be lost productivity. Like, we could know those, but that wasn't the extent of what they write. They wanted to know the economic value of each of those. And that was what we thought was a big mountain decline because we didn't really know how to do this. And from digging into literature, we didn't find anybody else that had ever done this either. And so that leads to a big challenge where you've got to say, a, what do we do? I think you know, after some moments of like, Okay, right, we can figure this out. You break it into smaller components. And so we realized pretty quickly that we needed to break this down. My team and I, which I'll show toward the end, there's a lot of people involved in this, and so it's certainly not. But I'm certainly not the only one. But we dug into the literature. That was kind of the first thing. What components do we have to go from? What have other people done? How can we expand or improve on those methods? And there was a lot of good work that had been done on narrow scopes. So for example, there was a couple really good papers on the economic burden of schizophrenia, for example. And so we could say, Okay, here's a starting point. Again, depression and mood disorders, we could find little pieces. Here are the Some of the methods. Here are some of the consequences. Here's some of the economic value. We started putting it all together and trying to figure out, The Baber Health Commission not asking us for just schizophrenia on its own. They want to know comprehensively. And so how do we put all this together? And a couple of things started coming and clicking. The hardest challenge, I think, was figuring out, well, how many people does this impact? How do we even get at that? This is a question of not who has a diagnosed mental illness, but who has not been treated? For something, which could also mean they've not been diagnosed at all. And so what we ended up finding, and I'll show you some numbers from this, but there's a national survey done every year called the National Survey of Drug Use and Health. And what's really fortunate for our research question in this case was that they asked people about mental health symptoms. They have a screening tool. And then they asked them, did you get treatment for those symptoms? And that was really key for us. That allowed us to say, Oh, here's the prevalence of untreated mental illness in the state. We could do some math and figure that out. This also led us what was fortunate about that survey was it was at the Indiana level, so we could say, here's the population of Indiana that's likely affected. We also were able to compile a list of consequences that were backed by literature. This is what we know is associated with mental illness in terms of potential economic consequences. And I think it's important at this point, I kind of pause to say, like, it's easy to say, Oh, you're just looking at costs, is that the most important thing? And I think that isn't what I'm saying at all. I think there's a lot of important thing. This is a big issue for families all across the state all across the country, but putting it into the economic context is just another way of sort of framing the picture. And so um, when I show you our list of costs, right? We know that the problem runs deeper than that, but we have to kind of do what we can estimate. And so that was important to us as well, to have that list that was based on evidence that we could then estimate. The other thing too that was we knew from the beginning that this was going to be challenging this needed to stand up to scrutiny. We know that first off, when you're doing something that nobody else has done, that in of itself is inviting scrutiny. But we also knew that The Behavioral Health Commission was going to take our data and they were going to make recommendations to the state legislature. And we needed this to be as not only rigorous and meticulous, but documented. And so that if people had challenges to our results, we could say, Yeah, here is how we came with that. A conclusion. Here is the assumptions we made. Everything is laid out for you. And I think that's important, right? That shows that we're not trying to hide anything. We're not trying to estimate numbers that we can't put a literature based backing on. And so we were very I don't want say concerned, but we were very meticulous in our ability to do that. And have everything not just documented, but also linked and so you could find out where the cost came from. I think this is important in this case, but as scientists, too, right? This is part of the scientific process. We want people to say, Oh, hey, do you think about this? Why didn't you do that this way? Like this dialogue is important because at the end of the day, we wanted to provide really good evidence to the state, but we also wanted to provide evidence for other researchers, other people in these types of positions across the country who might want to replicate this for their state. And so we wanted to make sure that they had, you know, a playbook that they could work from, too. So jumping into sort of what we concluded or what we determined. These were the 16 sort of areas of costs that we found to be really estimable from the evidence. And so I've kind of broken them down into groups. So the blue section there are healthcare expenditures, direct health care expenditures. We know that, for example, folks with certain mental health conditions or mental illnesses. It can lead to an exacerbation of other chronic diseases. For example, there's heart disease that can go unmanaged or improperly managed, and then that can lead to higher costs. So what we did in this blue section, these healthcare expenditures, these are not related to treating any sort of mental condition, mental health need. This is costs subtracting those and saying, this is a population who has been newly diagnosed or has sorry. A population who is likely to have a mental illness, what is their costs compared to somebody who doesn't in everything else but the mental health aspect? In the green section there. This is direct costs that the state has that so for example, the state spends money on prison, jail, homeless shelters, I think. These are line items from the state budget, and then we found and we constructed a way of estimating how many of these costs are likely in that population of people who had an untreated mental illness, not any mental illness, but that fraction who didn't receive treatment. And then lastly, the purple. These are indirect costs. And these in some cases, don't really have a line item. In other words, the, the state budget isn't going, Oh, hey, here's how much we spend on unemployment or productivity. But these are more economic values. And there's various methods to do this. For example, premature mortality uses a method called the human capital. It says, Oh, for every year of life lost through suicide, for example, there's an economic value of that. And so we tabulated this for one year based on the data that we have. Again, I'm going to be light on the methods. Here. There's ample documentation. We can talk about it at the end, but I've also provided a link so you can really see, like I said, we really tried to document it thoroughly. And Justin, there is a question in the Yes. Chat, wondering if your data is adults only or if it includes children because very relevant. So we do have kids included. There was another survey. So the The National Survey of drug sorry. Yeah. Drug use and health doesn't include children. But there is a survey that does. It's called the National Survey of Children's Health, and they do a similar type question, sort of how many children have a symptom and how many got treated. And so we were able to estimate that. So very good question. We included not only costs associated with children who are not working, but that led us to be able to estimate caregiver costs. So how much was spent by people who needed to care for. Maybe an older child that had a condition that, you know, maybe required extra care. So putting this here, this is the prevalence of mental illness in Indiana, but more specifically, this is those who needed treatment, but didn't receive it from the survey. This really is like our denominator or our ability to say, Okay, now that we have a population, that we can wrap our head around, how do we estimate economic costs? Through this, we were able to estimate basically 6% of Indiana's adult population has an untreated mental illness. 3% is what's considered a serious mental illness, and these are SAMs definitions. Again, that all what we considered serious and what we considered a mental illness. The definitions we document in our paper in our report very clearly. But 6% is a pretty high number when you think about what that means. Again, not people this is people who are not getting treatment for some symptomatic condition that that they felt even that they needed treatment for. And so from here, Again, skipping over some of the methods, but basically, we were able to estimate for all of those costs that I showed you, what is the excess risk of all of those outcomes, or what is the excess consequence by having a mental illness untreated. And so you can kind of think about that as, Okay, here's what the risk is for people with mental illness, and here's the risk for the population without, and then we assume so again, we document these in our paper, but that was how we were able to do it. What it resulted in was this large table that has broken down all of the different categories of costs by serious mental illness, other mental illness and children. So the reason Sirius versus other is distinguished is because we assumed from the literature, serious mental illness had different attributable costs. They might be more expensive. And so the input parameters differ. What I think this is hard to see, maybe, but it's also a lot of information. But what The key take home messages is the 4.2 billion dollar that we can pinpoint in economic costs. Again, some direct some economic value, some indirect, you know, type costs. It's a really big number. And it kind of highlights the need for action in our opinion. And so we provided this information to the Behavioral Health Commission, and they compiled. This wasn't their only mandate. They had other reports that they compiled and made recommendations. And so they put this all together in a report that came out. I think I saw somebody link that and I've got a link at the end. If you're interested. There was several recommendations, some that you might have already known about, like the 988 for a crisis response in it's an alternative to 911 for a mental health crisis. Also transitioning community Mental Health Centers to certified community Behavioral Health clinics. You know, all these recommendations were put forth by the Vavior Health Commission. And I think one of the things that they recommended or some of those recommendations then were translated into policy action. Again, a small portion, but our work, I think, helped inform and put the context that action was needed. So Senate Bill one was introduced, and in the legislature called Behavioral Health Matters. This policy set forth a lot of those recommendations, funded 988, put money towards transitioning the care delivery system. And so our research team, my colleagues, engineer, Menachemi, on the left and Heather Taylor on the right, we're actually called to testify in front of the legislative body to the evidence in our report for Senate Bill one. So this that's I think a really cool opportunity to have our work being testified as real evidence for policy. And if you didn't already know that bill was passed and was signed into an Act and pretty comprehensive mental health reform in the State of Indiana. And so this is still sort of on, you know, developing what the transitions will look like, but really a big investment in mental health resources in the state of Indiana. And I think when we saw this, that we were very satisfied that our work was able to be some part of getting this changed, but, as scholars, as researchers, as academics, the work doesn't stop there. And so we were able to then pursue publication of our methods predominantly. The results are important, I think. The results are important for the policy. But our methods were equally important because we want other people to be able to do this. We want to be able to do this potentially again in this state and see how it's changed over time. And so having a record of this, having a very detailed record of this, in fact, was important. And so we were able to publish this in the Jama Health Forum. It's open access. I'll have a link for it if you're interested. But that's also what this is about. So policy action, scholarship, and I think, as I said from the beginning, this is what I look to do. The ideal set of sort of the ideal pathway for research. We provide evidence to decision makers, we show our work, we produce a publication. And then now, you know, what comes next is following it up? What can we do to advance the work? So a couple points of discussion, right? I didn't get into a lot of the methods, but I will talk about some of the limitations, right? You probably sitting there thinking, why didn't they think about this cost or there's other costs associated with mental illness that weren't considered. Yeah, that's true. There's a couple of reasons. So maybe we overlooked it. But also we needed things that we could, as I mentioned, document. We needed things that the literature said, There is evidence that this is associated with this so that people can't poke holes in the argument, say, Well, that doesn't really, that's dubious. We wanted things that were very well established. So things may not have made it in. Another big assumption, I think that's key here is that we can't assume that treatment is going to be fully restorative, meaning that, if we had enough treatment for everybody, we would recover all 4.2 billion dollar at the state level. That's not what we're saying. But I think the exercise is useful to put in some frame of reference, right? This is what we see. But we recognize that this is not necessarily true. But I think we do show in our work that there is a good reason to believe the evidence. The other thing that is maybe even scarier, to be honest is that we didn't include substance use. And this was a decision made by the Babalth Commission to say, k, we can just focus on mental illness or mental health. And we know there's co occurrence between mental health and substance abuse. But they aren't totally overlapping. And so you think about what substance use and substance use disorder might add to the equation, and that gets really concerning at the economic value. So that's an opportunity, I think in the future. And so other opportunities, right? So again, this wasn't a cost effective analysis. We don't know what the return on investments going to be. I think a lot of those questions as we see this policy action being taken and unfolding, we'll need to look over time, see if some of these interventions are making an impact on reducing costs using the same method, seeing if more people are getting treatment. I think that's sort of an easy one to see if these new care models do that. So there's a lot of opportunities for that. I want to really highlight this was a big team. Heather Taylor was really instrumental in doing this work with me. She's probably the brains behind this, I would say, and also really instrumental in documenting everything so meticulously. Erin Zi really was kept the trains running on time and made everything work smoothly, and so I wanted to shout out in particular. I'll wrap up real quick with a couple of things on ys, Indiana. Again, we're in our 50th task order. But here are some highlights that we've just closed out. We've recently done a project evaluating intensive outpatient therapy, which is a residential alternative to substance use disorder and other mental health. We looked at how Telehealth might compare to person offerings of that for the state. We provided some recommendations on that. We're also looking at Division of Aging and analysis of nutrition, and we're planning things for the Indiana Pregnancy Promise Program. And so there's a lot of exciting stuff on the Hizon for Wise and showing some of the engagement. We've engaged 55 experts since July. So this is again, a really collaborative interdisciplinary partnership, including 30 trainees. And so we're really trying to involve trainees in this. I want to plug wise if you're interested and want to know how you can get involved, this link would help you fill out the expert directory. And this is a way that we can contact people say, Oh, you identified mental health as interest of yours or research. We have a mental health task order, we might be able to tap in and find a way to map your expertise to that project. A couple of other things that I wanted to talk about was we're working with FSSA to help facilitate data requests from external I want to say external, from other researchers, not just through wise task orders, for example. And so that's a process that we can hopefully help make this data process a little easier to navigate for researchers. And we're also doing things like Medicaid works and progress, where people who want to be involved in this research can kind of learn about what the data look like and some policies. So probably want a little longer than I should have, but we've got some time for questions. This QR code will get you to the article that has all of the methods, all of the assumptions that we made, and the top link is the behavioral health report, which I think was shared in the chat. So with that, I'll Be quiet and take some questions. Well, Justin, one question that was in the chat a bit earlier related to that chart you shared of the cost was if you could define presenteeism, because that was a huge piece of that cost part. They wanted to understand what that meant. That's a great question. So I think one of the things that surprised me perhaps was just how much of an economic value there was to employers in the state. And presenteeism is again, these are from the literature, but essentially, how effective or is there a penalty to how productive you can be if you're dealing with symptoms of an untreated mental illness. So a lot of this is in literature was, for example, mood disorders and major depressive disorders. There's evidence to suggest those folks that don't have that under control or don't have that managed with treatment are less productive. And so that's different than absenteeism, which means these are the estimated days of work missed because of a mental health condition. And so this is a big cost. And I think one of the reasons it's less about, this is a big, you know, line item. It's that it is very prevalent. And so there's a lot of costs On the aggregate in this category. Well, as people are thinking about questions, we invite you to turn on your camera, raise your hand, ask your question yourself. And I'll remind you that there are quite a few links in the chat. People have been very helpful to doctor Blackburn to put in some of the links to some of the articles and reports he's been talking about. We'll also send those to you afterwards. If you don't have a chance to grab them, we'll put out that way. But are there questions? Please, we'll open it up. Doctor Pierce, see you've unmuted. Hi. Thanks for a really informative presentation, doctor Blackburn. My work is to increase capacity for mental health care here in Indiana. And so building structures is great. But if we don't have the persons to actually provide the care, then we're still back at square one. So I'm wondering if the center has any projects going on with that. My project might dovetail nicely, but just really interested in anything else that you have going on. So thank you. And your presentation was really well taken. So thank you. Oh, for your good work. Thank you for saying all that. And I completely agree. So first of say, we don't have any workforce type projects now, but I completely agree with you that it isn't just, people aren't going to get treatment. There's bigger barriers, and it isn't just oh, we don't have enough, you know, clinics or you have to have people. And this is a shortage, not just in Indiana, but I think nationwide as you're much more qualified to you know, to say, but Yeah, I think that this is a multi factorial challenge of not just because one aspect might be and some of what DMH is, you've seen probably campaigns kick the stigma is one, and that's about getting people into treatment who think, Oh, this is not for me or that's one thing. But that's only part of the issue. I think the other issue is having enough people to serve the needs. And I complete hear you. I don't I don't have any work in that area, but it is super important. So we've been removing barriers by providing mental health care in schools. And one of the things that I noticed is in your chart that I really didn't see the learning needs. There's caregiver needs in adults, but the loss of good learning time because of mental health is really important. And that goes to the workforce down the road. In addition, by providing mental health care in schools, where we are removing barriers for sure. But I don't see that measured and I also don't see the school to prison pipeline measured. So I'm wondering if that was something that you also considered. In terms of, like, the costs of that program? No, not directly. So criminal justice costs were more about the incarcerated population, the per dim for that broken down by prison jail among children and adults. So great example of another cost that we don't have, which means our estimate is actually an underestimate, most likely. And so I appreciate pointing that out. My colleague has pointed out that actually, we do have some ongoing work in mental health or behavioral health workforce and a task order that Wise is part of. And so Notre Dame is actually leading a lot of that work to help recruit and retain innovative come up with innovative ways to recruit and retain the behavioral health workforce. So that's actually going on. And then there's also the state we may be doing some things with the transition to certi behavioral health centers I've lost the acronym, but that one may be upcoming too that would have a workforce component. I saw a question on. Performance metrics for inpatient psychiatric facilities. I think this is a great question. I love addressing quality and being able to measure quality and understand it. That wasn't part of this, but I think the quality of treatment is also super important for understanding. And so I think there's a few things that we're working on in this space, but nothing definitive. And then consumers with mental illness in the work. I think this is another really great point. Having stakeholders who are involved. That isn't something that our team looked at is this particular case, but it is having There's a little bit of a balance, right, because we don't want to the state partners don't necessarily want us to be burdening patients data collection and all this research. But I think having those voices are important, and that's how we can learn and really connect with people. So there's a balance. But I like the suggestion, we'll have to keep in mind of it. And in, I want to throw in another in looking at the comments to reflect on that you had mentioned the states current understanding of mental health and its importance? Mike Ker, Senator Kreider did a great job of highlighting that. That bill was not fully funded, but it was a good step in the next direction. But there is a lot of discussion now amongst agencies that I'm hearing about, we're in an election year. We're going to have a change in administration, and so we don't know what that will look like. You know, some of the candidates have already looked at their first question is, how do we cut the amount of money that we're spending in mental health as opposed to increase it. And so I'm wondering where there might be opportunities to translate the data that you have and how to present it in ways to show, I think what you're trying to say is, this is an important investment. We can save money by paying attention to this. But how do we do that? Yeah. Great point. I think as our role as scientists and as researchers, providing the best evidence is what we do. But it can't that's not going to be enough. In this case, that evidence has to get to the right people. That's the translational part. That's the key piece. I don't have a great answer. I don't know what's going to resonate the most. One of the reasons I started this talk and saying, here's the price of corn is that gets folks attention to say, Oh, Okay, this is a big deal. We also framed it in our report in terms of the number of jobs that can be created by that. And we're trying to put it in context where this is a tangible value. May be helpful. I don't know. I think though, having the evidence just is a big step because now you could say, h, well, we don't know we don't know what we can say, or we don't know how much that actually costs. Now you can. You can say, it's going to be over 4.2 billion dollar. I said, This is probably an underestimate. Well, I think that you're on the right track, given my understanding of where we live in a state that works, so we value workforce. So anytime we can highlight or present information that's going to support the workforce, which addresses some of the questions and the comments and we've talked about here that there is a shortage of workforce, or we don't pay them enough to stay in this field to do the work. And we should acknowledge that in this most recent legislative session, when they recognize there was a little bit of a deficit in the Medicaid spending of $1,000,000,000, that that really shook the legislature around how they're going to look at that. So next year is going to be an important year for people like you and your work to make sure that's out there and available. And I hope people today can get together and find ways to connect and to highlight the work in positive ways that will it can influence how we approach this in a positive way. Yeah, I appreciate you saying that, too. I think one of the things is we are fortunate with our relationship with Department of Mental Health and Addiction, I think to be able to have that agency, that division, asking us for evidence. That's a great step. But I think it's also important that other researchers, not just at IU, but in the whole community here are doing this work and that we can know what they're doing so that when we have platformed or when we have this, we can provide that evidence or have them engaged in the work that DMHA is asking us to do. And so long story short is, I think, saying, keep on doing the good work and we'll keep trying to make sure it gets misible and seen and promoted and has impact. Well, we want to take a pause here and thank you for sharing this information and encouraging people to think. We have a nice wide audience here with us today, and I hope that one of the outcomes of this opportunity is that people will connect beyond this discussion today and see where the opportunities are to use the data to find other ways to talk about the data and to address the many concerns that we all face and identify and our work with community partners as we involve students and other faculty and staff across our campuses. But we do want pause at this place because we know people have things that they need to do at the top of the hour, and you may have taken your lunchtime to join us. We appreciate that. We hope you join us again. However, we also will just hang out here. So while we're saying an official end to this program and thanking doctor Blackburn for sharing his information and encouraging us to think about it, we'll hang out for a little bit because we know some of you may want to still continue the conversation, and we're welcome to do that. But if you need to leave, please do that. Thank you for joining us. Come again and check us out on all of our social media and our website to learn more about translational research here at our Indianapolis campus of India University. We'll look forward to seeing you soon. So thank you, doctor Blackburn.