Fiscal Fitness: How States Cope

Improving mental health and substance abuse care with evidence-based practices

While there are evidence-based practices that could improve the care of those with mental health and substance abuse problems, the nation has yet to systematically implement those practices, according to Mental Health America (formerly the National Mental Health Association) CEO David Shern, PhD, who presented his concerns last year at the National Academy for State Health Policy (NASHP) annual meeting.

Dr. Shern noted that while the science base for interventions has improved, practices significantly lag behind the science base. Although good outcomes can occur if the high prevalence of behavioral disorders is treated early and well, he said, low rates of detection, treatment, effective care, and significant disparities lead to a very high morbidity and mortality burden.

Barriers to implementing evidence-based practices, he said, include work force preparation, work environment supports and incentives, knowledge development and dissemination strategies, policy-maker knowledge, demand side pressures for improvement, and differential values for treatments and outcomes.

System barriers to implementing evidence-based practices that Dr. Shern cited included reimbursement practices not tracking the evidence base; complex categorical funding streams frustrating integrated care; a narrow focus on agency specific budgets in cost containment; policy-makers unaware of evidence-based and informed practices; unavailability of systematic outcome and process data; and differing values for differing outcomes (reduction in hospital use versus normal life in the community).

There also are consumer and family barriers, Dr. Shern said, including the fact that stigmatized disorders inhibit information flow among consumers; research results are complex and difficult to interpret; differential power relationships with providers, particularly for people with mental illnesses; the fact that personal desires may not comport with supported treatments; and difficulty in determining if evidence-based practices are being provided.

Research barriers that can interfere with implementing evidence-based practices include a culture of research values that fails to map real world applications by controlling heterogeneity and restricts dissemination of research results to limited channels in peer-reviewed publications; limited systematic attention to implementing research findings; and limited opportunities to meaningfully interact with multiple stakeholders who have an impact on implementation.

"We devote 99% of our investment in intervention research to develop solutions," Dr. Shern said, "and only 1% to investment in implementation research to make effective use of the solutions. Because both implementation issues and implementation solutions are common across widely diverse domains, we have the foundation for effective implementation practices and for development of a science of implementation."

He tells State Health Watch that while there are both potential advantages and disadvantages to evidence-based practices, he believes the advantages outweigh the disadvantages. Dr. Shern notes that in health care, there is considerable variability in the care delivered and it often is not responsive to the population's health. Less than 50% of the care provided meets an evidence-based standard, he says.

Using an evidence-based approach is good, he says, because it provides a structured approach to dealing with a particular problem and eliminates bias that could lead investigators in the wrong direction. "Evidence-based practices have generally been shown to yield better care relative to other approaches," Dr. Shern says. "It offers the hope of introducing into behavioral health care a more standardized approach to reduce the variability."

He says the various barriers to implementing evidence-based practices he identified in his presentation are all important because they work together as a system. Regarding work force preparation, he calls attention to the need to find more responsive ways to train people so they will be more informed about evidence-based care. "This is a high leverage point because it is where we orient people to their careers," Dr. Shern says.

He also cites a need for more information technology support to help clinicians do better assessments and deliver more standardized care with benchmarks.

At the same NASHP conference, Michael Hogan, PhD, the former director of Ohio's Department of Mental Health, who has since moved to New York State, talked about what is involved in "selling" evidence-based practices in tight financial times.

"We have learned a lot in Ohio and around the country about what is termed implementing evidence-based practices in mental health," he tells State Health Watch. "Most of it is common sense, but many of the implications have not been well thought through or widely applied."

The context of mental health care and the nature of the "evidence" that is emerging tells the story, Dr. Hogan says. In the first place, serious mental illness is very complex and highly personal, since both thinking and feelings are affected. The impact of the illness and therefore recovery may involve aspects of biology, personality, learned behavior, disability, and culture. So, he says, the best care is expert and highly personalized and a patient's environment, such as stability of housing and social/family supports, is often crucial to outcomes.

"Much of the 'evidence' on effective treatment focuses on one or two aspects of this puzzle," Dr. Hogan says, "since 'evidence' in a world of medical research dominated by the randomized trial as a model depends on stripping away variability. So there are few evidence-based practices in mental health as simple as use of beta-blockers after a heart attack. The most research has been done on medication treatments, and it tends to suggest moderately more successful approaches that are likely to make a big difference for some patients/consumers, especially those whose conditions are not complex."

Dr. Hogan says promoting such practice improvements largely requires teaching practitioners new skills, and supporting use of these skills in their work, such as through electronic record systems that prompt for use of suggested treatment strategies.

"The strongest case and highest relevance for evidence-based practices in mental health is for team-based interventions that have many similarities to a chronic care model, although most serious mental disorders are better thought of as long term rather than chronic," Dr. Hogan says. "However, the qualities of these interventions, such as multisystemic therapy for acting-out youth and assertive community treatment for adults with schizophrenia, include variants of, for example, a multidisciplinary team, treatment in the live environment, continuing care with intensity tied to clinical status, and a highly personalized approach, require considerable effort to implement well."

According to Dr. Hogan, what has been learned about implementation of such efforts, or what he calls re-engineering, is wholly consistent with the literature on adoption of innovations. Leadership, adequate support for training, a supportive agency and financing environment, and the presence of ongoing mechanisms for assessing and modifying performance are all crucial, he says, while no single path strategy such as training, financing packages, or mandating compliance is effective.

"In some ways," he tells SHW, "the process of introducing evidence-based practices in mental health is like the experience of introducing quality improvement in complex manufacturing environments. But the challenges are far greater than manufacturing. What industrial process approaches the complexity of the human mind? And perhaps even more critically, how are such approaches put in place through highly dispersed, open social systems made up of multiple levels of government, competing regulatory and financing systems, and with thousands of providers working for largely autonomous organizations? The difference for consumers can be life and death, personal success, or long-term disability. The difference for taxpayers is in the billions."

Contact Dr. Shern at dshern@mentalhealthamerica.net and contact Dr. Hogan at (518) 474-4403.