Recommendations for Implementation

Dr. Robert Drake, a national leader in the move toward evidence-based practices, characterizes evidence-based practices as standardized treatments and services subjected to controlled research involving objective outcome measures and more than one research group. Evidence-based practices are built on scientific principles, and while they are supported by certain values and assumptions they are not themselves values; rather, they are specific interventions and treatment models that have been shown to improve client functioning and the course of severe mental illness.[1]

Among the evidence-based practices experts believe should be available in the public mental health system are: appropriate use of all available psychotropic medications; assertive community treatment; supported employment; family psychoeducation; illness self-management; and integrated treatment for co-occurring mental illness and substance abuse disorders. This is by no means an immutable list. In fact, it is expected that these currently identified practices represent just the leading edge of a much larger body of evidence-based practices that will result in more reliable standards for mental health services. Promising practices exist in a variety of areas, including rehabilitative services, supported housing, and case management, among others. Properly implemented, existing evidence-based practices have been shown to improve outcomes for both the client and the system. There is every reason to believe that if they were implemented more broadly, fewer people with mental illness would become involved in the criminal justice system.

 Studies show, for example, that people who are prescribed the newer, "atypical" antipsychotic medications experience fewer debilitating side effects than do clients taking the older classes of medications, with the result that they are more likely to adhere to their treatment regimens and thus to see the course of their illness improve. Yet the schizophrenia PORT study shows that the newer medications are seriously underutilized, especially in African-American and other minority populations, resulting in higher noncompliance with treatment and the familiar consequences of untreated mental illness.[2] The evidence shows that mental health service providers should make the newer medications routinely available to those who would benefit from them.

The Assertive Community Treatment (ACT) model (also known as Program of Assertive Community Treatment, or PACT) has been the subject of more than a quarter century of research showing its effectiveness with clients who do not respond to less comprehensive approaches. Since its inception in Madison, Wisconsin, in the 1970s, the ACT model has demonstrated that a mobile, multidisciplinary team approach, with services available twenty-four hours a day, significantly improves outcomes for persons with hard-to-treat mental illnesses. In some sites, persons with histories of criminal justice involvement or deemed to be at risk of criminal justice involvement have been identified as priority clients of ACT programs.

Despite the abundance of research that demonstrates ACT's effectiveness, providers and systems have until recently been reluctant to make the changes necessary to implement the program. Research is less clear on the factors that may have impeded implementation of ACT, but many providers note that it is difficult to change staff habits, program configurations, and patterns for state funding and federal reimbursement. In this way, the story of ACT is illustrative of some of the hurdles to be overcome by all evidence-based practices. So, too, is the recent upturn in ACT implementation, which stems from increased advocacy for the program at both the federal and grassroots levels, as well as clarification of reimbursement rules under Medicaid and other funding streams.

It is important to note that evidence-based practices are not all treatment interventions. Supported employment, family psychoeducation, and illness self-management are better seen as support techniques that ultimately allow a client to develop his or her self-reliance and personal strengths. Each in its own way can be a critical element in a person's recovery and ability to function, but none of these practices can be seen as direct treatment.

The U.S. Surgeon General and others have made efforts to gather and disseminate information about evidence-based practices, but it is apparent that a huge gap remains between knowledge and practice, between what is known through research and what is actually implemented in many public mental health systems across the country. A particular challenge for public mental health stakeholders is to ensure that evidence-based practices become more broadly available and more seamlessly integrated into existing systems of care.

The Surgeon General's 1999 report on mental health makes this challenge particularly clear. "Exciting new research-based advances are emerging that will enhance the delivery of treatments and services in areas crucial to consumers and families - employment, housing, and diversion of people with mental disorders out of the criminal justice systems. Yet a gap persists in the broad introduction and application of these advances in services delivery to local communities, and many people with mental illness are being denied the most up-to-date and advanced forms of treatment." [3]

Example:  New York State Office of Mental Health

The departments of mental health in Illinois, Maryland, New York, Ohio, and Virginia, among other states, have held or plan to convene conferences on evidence-based practices. The most ambitious of these was held in New York by the Office of Mental Health for the clear purpose of acquainting county-level policymakers and local service providers with national best-practice trends. The New York conference was the first step in a projected series of initiatives designed to make adherence to best practices a top priority in the New York public mental health system.

Example:  NASMHPD Research Institute

The National Association of State Mental Health Program Directors (NASMHPD) Research Institute is joining with the New Hampshire Dartmouth Psychiatric Research Center and the Medical University of South Carolina to develop methods for the dissemination of evidence-based practices. This effort, which various government and foundation sources support, is intended to provide hands-on assistance with replication of proven interventions. At the same time, research is under way to determine those factors that improve acceptance and implementation of proven models. This work has tremendous implications for the future of effective mental health services.[4]

Identification and implementation of evidence-based practices should not prevent innovation or the development of new practices. Many practices employed in the public mental health system have not yet been well researched. This does not mean that they aren't effective; in many cases, they simply have not attracted the attention of researchers or they do not easily conform to traditional research methodologies.  Researchers, providers, and practitioners should be encouraged to continue to develop new methods to serve people with mental illness who enter the system. Incentives for this activity should include an emphasis on outcomes in funding and contracting structures used for community services. Reliance on performance measures that emphasize recovery and improvement in a person's quality of life can lead to development of practices geared towards these outcomes. Providers should incorporate innovative approaches and methods expected to achieve good outcomes, paired with appropriate evaluation methods, into the practices employed by their agencies.

Research into effective medications and services is vitally important to the mental health field. Medical and rehabilitative advances of the past quarter century have changed our society's understanding of what is possible for someone with mental illness to achieve. Yet most researchers and practitioners agree that much remains unknown about mental illness and its treatment. As the Surgeon General's report on mental health notes, the nation must continue to invest in research at all levels to continue the trends benefiting many people today.[5]

The federal government sets much of the nation's agenda in basic, clinical, and services research. The research agenda is broadly encompassing; it should not overlook concerns of those people with mental illness who have contact with the criminal justice system. Practitioners and policymakers at the community level should be familiar with the research process and should promote continued support of federal agencies, such as the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration.

At the same time, the government should ensure that its policies and relationships with academic research centers and with industry promote research expected to benefit the same core group of disabled individuals. Close attention should be paid to provision of incentives that will ensure continuation of the progress this field has experienced in recent decades.

The research community also has an obligation to guard the safety of any human subjects involved in its programs. Mental health service providers must work with researchers to ensure that clients who participate in research understand the potential risks and benefits of the programs in which they take part.

Researchers and policymakers have noted the unfortunate truth that practice in the field too frequently fails to reflect what is known about the most effective practices available. This wide gap between what is known and what is in fact done results in lost lives, failed systems, and wasted resources.

Policymakers should ensure that practitioners employ effective mechanisms for knowledge dissemination of findings regarding promising practices and evidence-based practices in the systems they oversee. These mechanisms might include conferences, professional journals, academic partnerships, and regular in-service training opportunities. Contracts should include bonuses or other incentives for the use of evidence-based practices as well as for training and other dissemination practices.

Example:  Ohio Department of Mental Health; Illinois Office of Mental Health

Some state public mental health systems are accepting the challenge and taking steps to bridge the gap between research and practice. For example, the Ohio Department of Mental Health has established "coordinating centers of excellence" responsible for disseminating evidence-based or promising practices across the state. Eight of these centers are planned with the hope that they can promote local initiative and raise statewide quality measures. In Illinois, funding from the state Office of Mental Health has helped to establish the Illinois Staff Training Institute for Psychiatric Rehabilitation at the University of Chicago.