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Backgrounder
According to the President’s New Freedom Commission on Mental Health, “evidence-based
practice is the integration of best research evidence with clinical expertise
and patient values .1” The goal of these treatment approaches is to
ensure the best mental health treatments and services for people with
mental illnesses and their families.
Although evidence-based practice is not a new approach to treating many
chronic illnesses, it is new to mental health. In fact, its emergence in
the mental health field can be directly linked to the Surgeon General’s
1999 Report on Mental Health. And, it appears to be gaining popularity because
it compliments recent calls for accountability in mental health service
delivery.
Evidence-based practice, of which evidence-based medicine is one piece,
is a promising concept. It can be as reliable and scientific in the treatment
of mental disorders as it is for other chronic illnesses. And when applied
appropriately, it can increase accountability, improved quality of care
and patient outcomes and bridge the existing gap between research and practice.
However, there are challenges to implementing evidence-based practices
and concerns regarding the integrity of specific programs and policies labeled “evidence-based.”
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Some treatments and interventions may not yet have as deep an evidence-base
as other approaches although they offer quite a bit of promise and seem
to work. Eliminating access to these treatments and services because they
do not fit into the “evidence-based” category would only
serve to deny people treatments they need.
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Evidence-based approaches can be misused solely as a mechanism
to control cost. Specifically, many states and payors market fail first
programs, or step therapy, as “evidence-based.” These policies
merely restrict access to treatments by forcing people to "fail" on
one or more treatments, like medications, that the state or payor sanctions
as “preferred” before being allowed to access newer, more
effective treatments. And research shows that each individual reacts
differently to
treatments. So, people with mental illnesses need access to a wide
range of treatments in order to live, work and learn in the community.
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Many “evidence-based” approaches are not implemented
with fidelity to the original programs, or they may focus on only one piece
of the “evidence.” For example, mislabeled “evidence-based” approaches
often focus solely on symptom reduction scientifically, but not
at clinical experience and patient outcomes.
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Decisions regarding the criteria for “evidence-based” are
oftentimes made behind closed doors without the input of stakeholders or
consumers. It is also unclear what evidence is included when dubbing a program
or policy “evidence-based” and what is not. All available
evidence should be included. In addition, the quality and breadth
of the research
is often inadequate in that some populations are underrepresented
in the evidence. For example, people of color are often not adequately
represented
in clinical trials, so a full understanding of how culture affects
certain therapeutic approaches and how medications are metabolized
differently.
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Restricting access to treatments and services, either by misrepresenting
a cost-saving measure as “evidence-based medicine” or limiting
care to only “evidence-based practices,” is harmful to
both people with mental disorders and to the economy.
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Despite the fact that mental illness is very treatable with
the right access to treatments, only one-third of the 54 millions
Americans with mental illness receive any treatment at all2 . This
failure to
provide
the mental health services people need causes long-term and unnecessary
suffering, as well as a considerable strain on the U.S. economy.
- Each year, $113 billion is wasted on untreated mental illness
- $105 billion of which can be attributed to lost productivity alone3.
- Recent state health care cutbacks have lead to upsurge of people
with mental illnesses seeking care in emergency rooms - a much
costlier source
of treatment. The mental health treatment received in ERs
is not only less appropriate than care received in the community,
but
the burden
on ERs has
caused a negative affect on the care of all emergency room patients 4.
- People with mental illness who do not have access to care increasingly
find themselves warehoused in America’s prisons, jails and juvenile
justice facilities. In 1998, an estimated 283,800 adult offenders
with mental illness were incarcerated in the nation’s prisons
and jails5.
- Many victims of a poorly funded and neglected mental health
system become desperate enough to take their own lives. In fact,
more than 90 percent
of people who commit suicide have a diagnosable mental disorder 6.
- President’s New Freedom Commission on Mental Health, Final
Report to the President. p. 68, 2003.
- Mental Health: A Report of the Surgeon General, 1999.
- Rice, P. Dorothy &Leonard S. Miller. Health economics and cost
implications of anxiety and other mental disorders in the United States.
British Journal
of Psychiatry; 173(34): 4-9, 1998.
- National Mental Health Association et al. Psychiatric Emergencies
Survey. April 2004.
- U.S. Department of Justice, Bureau of Justice Statistics Special
Report: Mental Health and Treatment of Inmates and Probationers.
July 1999.
NCJ 174463.
- The Center for Mental Health Services, National Strategy for Suicide
Prevention branch: Mental Illness and Suicide – Facts. www.mentalhealth.org/suicideprevention/suicidefacts.asp.
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