Implementing Evidence-Based Practices for People With Schizophrenia

Article (PDF Available)inSchizophrenia Bulletin 35(4):704-13 · August 2009with90 Reads
DOI: 10.1093/schbul/sbp041 · Source: PubMed
Abstract
Over the last decade, a consensus has emerged regarding a set of evidence-based practices for schizophrenia that address symptom management and psychosocial functioning. Yet, surveys suggest that the great majority of the population of individuals with schizophrenia do not receive evidence-based care. In this article, we review the empirical literature on implementation of evidence-based practices for schizophrenia patients. We first examine lessons learned from implementation studies in general medicine. We then summarize the implementation literature specific to schizophrenia, including medication practices, psychosocial interventions, information technology, and state- and federal-level interventions. We conclude with recommendations for future directions.
Implementing Evidence-Based Practices for People With Schizophrenia
Robert E. Drake
1,2
, Gary R. Bond
3
, and Susan M. Essock
4
2
Dartmouth Psychiatric Research Center, Dartmouth Medical
School, Lebanon, NH;
3
Department of Psychology, Indiana
University-Purdue University Indianapolis, Indianapolis, IN;
4
Department of Psychiatry, Columbia University, and New York
State Psychiatric Institute, New York, NY
Over the last decade, a consensus has emerged regarding
a set of evidence-based practices for schizophrenia that ad-
dress symptom management and psychosocial functioning.
Yet, surveys suggest that the great majority of the popula-
tion of individuals with schizophrenia do not receive
evidence-based care. In this article, we review the empirical
literature on implementation of evidence-based practices
for schizophrenia patients. We first examine lessons
learned from implementation studies in general medicine.
We then summarize the implementation literature specific
to schizophrenia, including medication practices, psychoso-
cial interventions, information technology, and state- and
federal-level interventions. We conclude with recommenda-
tions for future directions.
Key words: evidence-based practices/schizophrenia/
implementation research
Introduction
Over the past decade, the US Surgeon General’s Report on
Mental Health,
1
the President’s New Freedom Commis-
sion Report,
2
Schizophrenia Patient Outcomes Research
Team (PORT) project,
3
the Texas Medications Algorithm
Project (TMAP),
4
and several other systematic efforts
5–10
have identified a variety of evidence-based interventions
for persons with schizophrenia. Examples of effective
interventions include systematic approaches to medica-
tion management, assertive community treatment, relapse
prevention programs, and supported employment.
Despite robust evidence on effective interventions, ep-
idemiologic and clinical surveys have established that
individuals with schizophrenia in the United States are
unlikely to receive these effective treatments.
11
Epidemi-
ologic data from the National Comorbidity Study in the
early 1990s showed that 60% of persons with serious men-
tal illnesses received no treatment in the past year, 25%
received clearly inadequate treatment, and only 15% re-
ceived minimally adequate (far short of evidence-based)
treatment.
12
The Schizophrenia PORT study similarly
found that patients in 2 large state public mental health
programs were unlikely to receive most of the indicated
evidence-based practices.
13
More recently, the 2005 Na-
tional Survey on Drug Use and Health
14
found that only
8.5% of adults who reported both serious psychological
distress and a substance use disorder received any treat-
ment (again far short of evidence-based treatment) for
both problems in the past year. Several recent studies in-
dicate that quality of care may be worsening rather than
improving.
15–17
Thus, even as researchers continue to de-
velop more effective interventions for the treatment of
schizophrenia, the preponderance of individuals with
this disorder, perhaps as many as 95%, receive either
no care or less than optimal care. Previous articles in
this special section have reviewed the epidemiology of
services and the problems of engagement and retention.
In this article, we review efforts to implement effective
interventions for schizophrenia in routine mental health
treatment settings and offer suggestions for narrowing
the gap between science and practice.
Implementation Research in General Medicine
Overview
Shojania and Grimshaw
18
summarized the general med-
ical literature on quality improvement efforts with 4 con-
clusions: First, the standard approach of passive diffusion
of research (ie, publication of research findings in profes-
sional journals), including dissemination of findings on
effective interventions, has little or no impact on routine
practice. Second, more complex efforts to synthesize re-
search evidence in the form of systematic reviews and dis-
seminated guidelines also have little or no effect on
practice. Third, adopting total quality management/con-
tinuous quality improvement techniques from industry
has produced modest but disappointing results. Quality
improvement, popularized by Deming,
19
is a process that
1
To whom correspondence should be addressed; Psychiatric
Research Center, 2 Whipple Place, Lebanon, NH 03766, tel: 603-
448-0263, fax: 603-448-3976, e-mail: Robert.E.Drake@dartmouth.
edu.
Schizophrenia Bulletin vol. 35 no. 4 pp. 704–713, 2009
doi:10.1093/schbul/sbp041
Advance Access publication on June 2, 2009
Ó The Author 2009. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
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704
focuses on training, education, and using data to enhance
the performance of an organization.
20,21
In mental health
treatment settings, quality improvement has taken the
form of field-based supervision and systematic review
of patient outcomes.
22–24
Fourth, current attempts at
complete systems reengineering using information tech-
nology have produced mixed results, including many
prominent successes, which need to be understood in
greater detail, as discussed below.
Disease Management Systems and the Chronic Care
Model
Health maintenance organizations have widely adopted
disease management systems that emphasize activating
patients for self-management, ensuring that clinical teams
have the relevant expertise and access to evidence-based
guidelines, and monitoring patients without face-to-face
contacts.
25
Wagner’s
26–28
chronic care model represents
the most clearly articulated and widely studied approach
to disease management. It explicitly aims to combine the
best available implementation strategies. The Wagner
model includes 6 components: (1) addressing ‘‘health care
organization’’ at the level of leadership, financing, and
removing barriers; (2) improving access to ‘‘community
resources,’’ such as self-help, self-management classes, and
nurse educator services; (3) enhancing ‘‘self-management
supports,’’ suchashelping peopleto setgoals, establishaction
plans, identify barriers, and solve problems; (4) establishing
‘‘care monitoring,’’ often by nurses or pharmacists, to mon-
itor response, self-management skills, and treatment by algo-
rithms; (5) providing ‘‘decision supports,’’ which incorporate
evidence-based guidelines into registries, flow charts, and
assessments, to clinical teams; and (6) instituting ‘‘clinical in-
formationsystems’’thatincludeassessments,treatmentplan-
ning, services, outcomes, and algorithms. Many disease
management programs include all 6 components, but others
include only a portion of Wagner’s model. The evidence
shows that disease management approaches improve quality
of care and outcomes across diverse chronic diseases such as
diabetes, asthma, cardiovascular disease, and depression.
29
Implementing Medication Guidelines for Patients With
Schizophrenia
Since the original Schizophrenia PORT study in the
1990s, several efforts have targeted implementing effec-
tive interventions, or evidence-based practices, for
schizophrenia patients on a large scale rather than as
small demonstrations. Because changing medication
practice involves a different set of providers and mecha-
nisms from changing psychosocial practice, we consider
implementing medication guidelines first.
Antipsychotic treatments are a mainstay of treatment
for schizophrenia, and most people with schizophrenia
who are in treatment have access to antipsychotic med-
ication. In the original Schizophrenia PORT study of ad-
herence to recommendations in routine practice, the
likelihood of a person hospitalized with schizophrenia re-
ceiving an antipsychotic medication was high (89%), but
the quality of the antipsychotic prescribing frequently de-
viated from the evidence-based recommendations (only
62% of inpatients and 29% of outpatients were prescribed
antipsychotic medication either within the recommended
dosage range or with chart documentation justifying the
dosage prescribed).
13
Because prescribing medications is
an essential component of treatment of schizophrenia
and is relatively easy to implement (compared, eg, with
mounting assertive community treatment teams or mul-
tifamily psychoeducational groups), administrators,
payers, and researchers have focused considerable
efforts on improving prescribers’ adherence to treatment
guidelines.
The Texas Medication Algorithm Project
The largest of these efforts, the TMAP, began in 1996
with the intent to develop, implement, and evaluate an
algorithm-driven treatment approach for adults with
major psychiatric disorders treated within the public
mental health sector in Texas (http://www.dshs.state.tx.
us/mhprograms/tmapover.shtm).
30
TMAP incorporated
several elements of Wagner’s chronic care model, includ-
ing patient education, systematic assessments, and clear
guidelines. The project encompassed 4 phases: (1) crea-
tion of evidence-informed algorithms via consensus con-
ferences that clearly indicated (via a flow diagram) the
sequence in which the various medication alternatives
should be considered (eg, ‘‘Consider clozapine before
polypharmacy’’), (2) a feasibility trial using the algo-
rithms with early adopters to estimate their clinical im-
pact and determine the resources needed to implement
them, (3) a prospective comparison of the clinical out-
comes and economic costs of using the algorithms vs
treatment as usual in outpatient public mental health
clinics, and (4) a broad implementation of the algorithms
throughout the public mental health system in Texas,
called the Texas Implementation of Medication Algo-
rithms. The goals of TMAP were simple but far-reaching:
to encourage measurement-based medicine to optimize
patients’ outcomes. By combining sequential treatment
algorithms with standardized measurements of symp-
toms and functioning at each visit, the prescriber could
track progress or lack thereof over time to determine
whether a medication change was indicated.
A wide variety of stakeholders followed TMAP closely.
Patients, family members, payers, and clinicians were con-
cerned about wide variations in prescribing practices and
lauded TMAP for seeking to reduce unwarranted varia-
tion and ensure access to evidence-based decisions regard-
ing medication management. Many other states, counties,
and systems of care modeled algorithm-driven interven-
tions after TMAP, even before results of the prospective
comparison study were available.
Evidence-Based Practices for Schizophrenia Patients
705
In the prospective comparison study, after 3 months of
treatment, patients with schizophrenia who received
treatment in the sites that were trained and staffed to
use the TMAP algorithms had greater improvement in
symptoms (about 3 points on the 18-item Brief Psychiat-
ric Rating Scale, after transformations of the scores to
adjust for baseline differences and other factors known
to affect health outcomes) than did patients in the com-
parison sites, but this difference in transformed scores
disappeared over time.
4
Patients in both algorithm sites
and nonalgorithm sites showed improvement over time in
test scores measuring cognitive functioning, with the
patients in the algorithm sites showing greater improve-
ment that was sustained as of the final (9 mo) measure-
ment of cognitive functioning. Whether this difference in
measures of cognition translated into differences in func-
tioning in everyday life is not known. Because the impact
of the score transformations used was so profound (eg,
using raw scores reported in table 2 of the 2004 report,
after 3 mo of treatment the symptom scores for the algo-
rithm sites improved by about 5 points compared with
improvements of 6 points at comparison sites that
were implementing an algorithm for a disorder other
than schizophrenia and improvements of about 6 points
at other comparison sites), TMAP analyses may best be
considered unfinished. Further exploration of this valu-
able dataset could provide much needed information on,
eg, whether patients of prescribers who became more
guideline adherent over time showed greater improve-
ments in outcomes than did patients of prescribers
who remained less adherent. Given the large impact in
this study of score transformations on outcomes, sensitiv-
ity analyses showing the impact of various transforma-
tions could inform interpretation.
By design, the TMAP intervention included compo-
nents to support and encourage the use of the algorithms
in addition to the algorithms themselves. The TMAP
investigators recognized that passive diffusion of algo-
rithms was unlikely to change practice. The intervention
package at a site included the provision of a clinical co-
ordinator to work with physicians and families, treat-
ment manuals, expert consultations through conference
calls and site visits, family education programs, standard-
ized assessments of symptoms and side effects, as well as
the enhanced record keeping procedures that accompa-
nied use of the algorithms.
31,32
The understandable con-
founding of these intervention components means that
one cannot know the extent to which any of the individ-
ual components were responsible for TMAP’s findings.
What at first blush looks like an expensive intervention
(training across sites, implementing measurement tools
for prescribers to use to monitor changes over time,
and placement of a clinician in each site to work with
physicians to help them follow the guidelines) for a mod-
est impact may be too pessimistic a conclusion. No
doubt, adherence to the guidelines varied across prescrib-
ers, even within the algorithm sites. A stronger test of the
payoff of changing prescriber behavior to more closely
follow the treatment algorithm would be to determine
whether patients of psychiatrists who followed the algo-
rithm more closely had better outcomes than patients of
psychiatrists who followed the algorithms less closely.
This remains a challenging analysis for a multitude of
reasons. Nevertheless, knowing whether and to what ex-
tent efforts to enhance adherence to guidelines improves
patient outcomes is critical for policy makers who must
decide if they should go to the effort of implementing and
sustaining the use of such algorithms.
Beyond TMAP
The zeitgeist surrounding TMAP prompted public and
private payers to identify questionable patterns of pre-
scribing and to intervene and monitor the impact of
such interventions. The Psychiatric Clinical Knowledge
Enhancement System in New York provides detailed cur-
rent medication regimens and histories at the patient, psy-
chiatrist, ward, and facility levels and has been used to
decrease rates of antipsychotic polypharmacy.
33,34
In an-
other effort aimed at increasing prescriber adherence
to evidence-based guidelines, a statewide longitudinal
project in Kentucky examined the impact of prescriber
training and systematic monitoring of medication prac-
tices, using Medication Management Approaches in
Psychiatry (MedMAP) (mentalhealth.samhsa.gov/cmhs/
communitysupport/toolkits/community/), which is an
adaptation of the TMAP schizophrenia module. The
Kentucky Project used the MedMAP Fidelity Scale
35
as
a quality improvement tool and documented modest im-
provement in prescribing practices over a 16-month period.
36
The last decade has also seen the emergence of phar-
macy management companies that contract with employ-
ers to review patterns of utilization, establish preferred
drug formularies to steer patients toward/away from par-
ticular costly and/or more effective medications, and send
letters to patients or prescribers alerting them to potential
concerns about the medication regimens used. The extent
to which steering is influenced by cost vs quality concerns
typically cannot be determined because the full list of
such managed care firms’ algorithms typically is propri-
etary, making it difficult for the payer or a neutral third
party to evaluate the attention paid to cost vs quality of
care by such algorithms. Firms may use polypharmacy as
an example of a clinically questionable practice their
guidelines target but offer few other specifics. While
physicians can be offended by receiving ‘‘Dear Pre-
scriber’’ letters from such pharmacy management firms
and suspect that the goal is cost containment as opposed
to quality improvement, one also can imagine situations
in which strong evidence supports the use of timely claims
data to flag clinically questionable situations for review
(eg, no use of an antipsychotic medication following
706
R. E. Drake et al.
a hospitalization for schizophrenia). Transparency via
independent review and broad opportunity for public
comment helps quell understandable concerns that algo-
rithms could be promoting cost savings at the expense of
improving clinical outcomes. The business of promoting
adherence to particular practices is rife with controversy
as well as essential for improving care.
37
Research on Implementing Psychosocial Interventions
Disseminationofmodelpsychosocialprogramsfor individ-
uals with schizophrenia has a long history, dating back to
the 1970s with the failed effort to promote the use of com-
munity lodges for patients discharged from psychiatrichos-
pitals.
38
In the late 1970s, the National Institute of Mental
Health (NIMH) began funding the dissemination and eval-
uation of promising models based on Community Support
Program principles to promote community integration of
individuals with serious mental illness.
39
Many of these
projects produced disappointing results, in part due to
poor model specification,
40,41
inadequate implementation
plans,
42
lackofstakeholdersupportforthe dissemination,
43
and inadequate leadership.
44
Many projects launched dur-
ing this era had naive assumptions about the minimum
requirements for effective implementation. The challenges
of implementing complex psychosocial interventions are
much greater than those for medication interventions.
45
One positive outcome from the Community Support
Program demonstration projects was increasing awareness
of the need to define adherence to program models, which
in turn required clearly defined models. Building on the
work on treatment integrity in the psychotherapy litera-
ture,
46,47
researchers began developing fidelity measures,
defined as methods to assess adherence to the standards
of a program model.
48
Among the earliest of these efforts
were measures to assess adherence to the assertive commu-
nity treatment model.
49–53
Assertive community treatment
was the most clearly defined of the psychosocial models at
the time.
54
In the 1990s, supported employment began ac-
cumulating a strong evidence base, and a fidelity scale was
developed and validated for this model as well.
55,56
For
supported employment, fidelity has been found to be as-
sociated with higher competitive employment rates.
57–63
For assertive community treatment, the correlation
between fidelity and improved outcomes has been less
consistent.
51,64–66
Over the last few years, there has been greater emphasis
on the systematic study of the implementation process. In
2006, a new journal was established devoted to this en-
terprise (http://www.implementationscience.com). Ac-
cordingly, the literature on strategies and barriers to
implementing evidence-based practices has expanded
dramatically.
45,67
With regard to schizophrenia, recent
projects employing systematic implementation strategies
include the National Implementing Evidence-Based
Practices Project, the Mental Health Treatment Study,
the Department of Veterans Affairs (VA) dissemination
of supported employment, several learning communities,
and a variety of implementation studies outside the
United States.
National Implementing Evidence-Based Practices Project
In 1998, a national panel of experts convened by the
Robert Wood Johnson Foundation recommended that
5 psychosocial practices and systematic medication man-
agement be offered in every community mental health cen-
ter.
8
The panel also recommended the development of
a systematic approach to dissemination. The National
Implementing Evidence-Based Practices Project was
launched to address the aforementioned deficiencies.
68–72
The investigators hypothesized that implementation of
evidence-based practices in routine settings minimally
required comprehensive, user-friendly information about
the practices and their implementation—resources gener-
ally unavailable in earlier dissemination efforts. Therefore,
the first phase of the National Evidence-Based Practices
Project involved creation of toolkits for each practice, con-
sisting of a variety of materials to facilitate practice imple-
mentation, such as practitioner workbooks, research
articles, introductory and instructional video, and Power-
Point lectures. The toolkits aimed at multiple stakehold-
ers, assuming that success depended on active support
from the state mental health authority, agency leadership,
practitioners, consumers, and family members.
The investigators also hypothesized that, in addition to
the toolkits, another necessary component for successful
implementation was systematic training and consulta-
tion. Thus, the project researchers developed a training-
consultation model that included the following
elements
71
: (1) consultation to the state mental health au-
thority, (2) consultation to community mental health cen-
ter administrators, (3) a kickoff presentation to the
provider agency, (4) provision of the evidence-based
practice toolkit to the agency, (5) initial skill training
for practitioners, (6) ongoing consultation to sites, and
(7) systematic fidelity monitoring. Fidelity monitoring in-
cluded 2 steps: (a) fidelity assessments based on daylong
site visits by a pair of independent fidelity assessors who,
guided by fidelity scale criteria, conduct structured inter-
views, observe team meetings and interventions, and re-
view medical records and (b) fidelity review meetings held
with agency leaders in which assessors give oral and writ-
ten feedback on quality of implementation.
73
The second phase of the project was a field test of 5
psychosocial evidence-based practices in 53 sites in 8
states. The sites were studied over a 2-year period. Assess-
ing clinical outcomes would have been prohibitively ex-
pensive; therefore, the study focused on fidelity scores at
baseline and 6-month intervals. Findings from this pro-
ject are now appearing in the literature.
24,73–84
Overall, 29 (55%) sites showed high-fidelity implemen-
tation at 2-year follow-up.
79
Most sites achieving high
707
Evidence-Based Practices for Schizophrenia Patients
fidelity did so within the first year of implementation.
Two of the evidence-based practices (assertive community
treatment and supported employment) were more readily
implemented than others. Based on qualitative data col-
lected within each site, several factors influenced quality
of implementation, including the state mental health
authority’s provision of leadership, funding, and practice
standards
76,80,85
; skilled mentoring by trainer-consul-
tants
24
; administrative support and competent clinical su-
pervision at the site level
24,74–77,81
; systematic monitoring
of fidelity and outcomes
73,78
; and staff turnover.
83
Mental Health Treatment Study
In 2006, the Social Security Administration launched a 23-
site randomized controlled trial comparing an experimen-
tal program to usual services for Social Security Disability
Insurance (SSDI) beneficiaries with schizophrenia or af-
fective disorder.
86
Beneficiaries in the experimental condi-
tion receive a comprehensive package of services including
supported employment, systematic medication manage-
ment, and other behavioral services. A nurse care coordi-
nator assigned in each site helps to ensure that services are
individualized and evidence-based. The experimental
group also receives supplemental insurance to cover
charges for all necessary health care. Building on the expe-
riences of the National Implementing Evidence-Based
Practices Project, a quality management team is monitor-
ing fidelity and providing technical assistance to the sites.
Many of the same themes have emerged from this project
as in earlier implementation studies. Barriers include the
maze of state bureaucratic regulations even in the face of
a well-funded project, the pivotal role of site leadership,
the challenges of integrating supported employment
with mental health treatment services, and staff turnover.
Department of VA
Like an earlier dissemination of the assertive community
treatment model,
42
current efforts by the Veterans Health
Administration of the Department of VA to disseminate
supported employment are ambitious in their national
scope.
87–89
Organizational barriers include lack of
resources for supported employment, fragmentation of
services (with individual clinicians working indepen-
dently), and VA traditions and policies not aligned
with evidence-based supported employment. In addition,
longstanding sheltered and transitional work programs
within the VA conflict with the principles of supported
employment. This project depends on mostly remote su-
pervision and monitoring, which may dilute the impact of
technical assistance and quality improvement efforts.
90
Learning Community Approaches
Borrowing from higher education, some groups of health-
care organizations have adopted a learning community
approach to quality, forming networks among key staff
from these organizations that share common values and
beliefs and are actively engaged in learning together
from each other.
91
Learning communities are especially
suited to promoting sustained adherence to a practice as
well as continuous quality improvement by creating
a culture of peer accountability and sharing among par-
ticipating organizations. One such application to schizo-
phrenia has been a network of state and local leaders
aimed at disseminating evidence-based supported em-
ployment.
92
First established in 2002, the network has
now grown to include participants from 10 states and
the District of Columbia. Using familiar strategies
such as annual meetings, newsletters, development of
videos, on-site trainings, bimonthly teleconferences,
and sharing data, this network has stimulated interest
in identifying innovative implementation strategies suc-
cessful in one state that are adapted for use in others.
93,94
Program evaluation data suggest growing access to sup-
ported employment and achievement of site-level com-
petitive employment rates exceeding 40% for quarterly
reporting periods.
92
A similar project in New York State, the Wellness
Self-management Program (a variation of Illness Man-
agement and Recovery
95
), also uses learni ng col labora-
tives.
96
Teams from participating sites meet to describe
implementation experiences and hear suggestions from
colleagues as well as a trainer-facilitator.
International Efforts
Wide-scale dissemination of evidence-based practices has
been attempted in Canada,
97
various European coun-
tries,
98–100
Australia,
101
and Japan.
102
Common barriers
found in these projects have included funding issues, lack
of cooperation among different services (eg, vocational
rehabilitation, mental health, and substance abuse treat-
ment), staff turnover, and insufficient time allocated for
program leaders.
Information Technology
Both the Institute of Medicine
103
and the New Freedom
Commission
2
recommended using modern information
technology to improve the quality of mental health
care in America. The United States lags behind other
Westernized countries in the use of health information
technology,
104
and the US mental health system lags be-
hind other areas of American medicine.
11
Several recent
reviews conclude that appropriate use of information tech-
nology can improve quality of health care.
105,106
A simple
example of psychiatric knowledge enhancement systems
is the use of programs that check for medication interac-
tions and incorrect dosages. Other common components
include increasing patient input regarding status, concerns,
and goals; increasing patient education regarding evidence-
based practices; increasing practitioners’ awareness of
708
R. E. Drake et al.
evidence-based treatments and algorithms and of patients’
concerns and preferences; identifying and avoiding medical
errors; enhancing shared decision making; monitoring out-
comes and side effects; and monitoring programs and sys-
tems of care.
107
Comprehensive electronic decision support
systems, which address all these components, are just
emerging in mental health. The Veterans Administration
has adopted a clinically oriented electronic medical record
that facilitates evidence-based care via patient-specific clin-
ical prompts, monitoring of care, and review of outcomes;
the system has recently added a patient portal (http://
www.myhealth.va.gov/). Enhancements to the Veterans
Administration electronic medical record for mental health
arebeing tested,
108
andfeasibility testingof directconsumer
use of computer systems has shown promising results.
109
In
several European Union countries, a computerized system
that enables patients with schizophreniaand their clinicians
to compare their perspectives on goals and negotiate plans
has demonstrated improvements in satisfaction, reduced
unmet need, and increased quality of life.
110
Numerous innovative efforts are underway.
111
Deegan
et al
112
have designed a comprehensive electronic decision
support system that is used to facilitate shared decisions
during medication visits. Similar systems are being cre-
ated and tested within the Department of VA to support
schizophrenia care as well as care more broadly and at the
Dartmouth Psychiatric Research Center to support treat-
ment planning, smoking cessation, employment services,
co-occurring disorders treatments, and care of comorbid
medical illnesses. The New York State Office of Mental
Health also is developing a consumer portal to support
decision making around medications.
Comprehensive electronic decision support systems
must be integrated into real-world contexts to be use-
ful.
105,106
Deegan et al
112
established a recovery resource
center within a routine community mental health center
by providing semiprivate computer kiosks, visual and
oral information, and peer supports. Patients and clini-
cians achieved high levels of participation and satisfac-
tion. Of course, much of current community mental
health work is done in the community rather than in clin-
ics. Demonstrating that electronic resources can be deliv-
ered in other forms, such as through health buddies, in
peer support centers, on the web, and on portable infor-
mation systems that case managers and other clinicians
carry with them, will be important.
113
The Role of Government
State Interventions
In the United States, the role of state government in pro-
moting and inhibiting the growth of evidence-based prac-
tices is enormous if not decisive.
114–117
The reasons are
obvious: State agencies, in conjunction with federal agen-
cies (notably the Centers for Medicare and Medicaid
Services) to a large extent determine what services are
funded or not funded. In most states, the state mental
health authority has sponsored statewide initiatives
to promote evidence-based practices. States have ag-
gressively promoted adoption of assertive community
treatment,
76,80,118
supported employment,
93
family psy-
choeducation,
43
integrated dual disorders treatment,
119
and medication management approaches.
30,33,36
A pop-
ular but ineffective approach has been the sponsorship
of statewide conferences.
120,121
To address the enormous
costs of face-to-face meetings, some states are exploring
web-based options for training and ongoing supervision.
A comprehensive approach to enhancing broad dissem-
ination has often been centered in the formation of tech-
nical assistance centers providing consultation, training,
and fidelity monitoring.
24,118,122,123
Althoughitis widelyassumed that thestate mentalhealth
authority critically impacts the development of evidence-
based practices, most research to date has been anecdotal.
To test this hypothesis, a state-level fidelity scale was devel-
oped for the National Implementing Evidence-Based Prac-
tices Project to measure objective indicators of state mental
health authority actions, such as the designation of a point
person within the state agency responsible for dissemina-
tion, the establishment of a technical assistance center,
state-level policies and regulations aligned to support the
evidence-based practices, and provision of financial incen-
tives to implement the evidence-based practices. This state-
levelfidelity scale wasstronglycorrelated withmean fidelity
for the evidence-based practices in each state.
85
To date, most studies of statewide implementation have
examinedearly stagesofdisseminationinwhich enthusiasm
and other Hawthorne effects abound. Much less is known
regarding sustaining a statewide initiative, especially in the
face of the frequent leadership changes in senior staff
in many state agencies due to postelection changes in polit-
icalappointees.Fromthestandpointofthedirectorsofcom-
munity agencies, decisions about adopting evidence-based
practices are influenced by judgments about the perceived
riskiness of the uptake, anticipated resource availability,
and exposure to evidence.
124,125
Early adopters are willing
to mounttheinitiatives necessary for adoption because they
see the risks associated with adopting as lower and more
manageable than nonadopters.
124,125
Discontinuation
is driven in part by staff turnover
126
; hence, e-learning
approaches that are permanently and conveniently accessi-
ble can also help deal with this challenge.
Federal Interventions
At the federal level, the 12% set-aside of the NIMH budget
for services research helped launch TMAP and other stud-
ies of the effectiveness of various treatment approaches.
That set-aside is long gone, but, as this article is being
written, the current version of the federal economic
stimulus package contains $400 million to the Agency
for Healthcare Research and Quality as well as other funds
709
Evidence-Based Practices for Schizophrenia Patients
to stimulate comparative effectiveness research. As the
largest single payer for health care in the nation, the Fed-
eral government can make significant investments in nar-
rowing the quality chasm between what is known and
what is practiced. In theory, NIMH generates new knowl-
edge, and the Substance Abuse and Mental Health Serv-
ices Administration helps such knowledge make its way to
real people in real-world settings by promoting ways
across this chasm. Knowing how to promote such uptake
and where one’s efforts are best invested are themselves
pressing research issues. The Social Security Administra-
tion also has shown an interest in promoting evidence-
based employment programs. It sponsored an expert panel
to identify a package of evidence-based interventions
to help SSDI beneficiaries with mental illness to return
to work.
127
The work of this panel led to the funding of
the Mental Health Treatment Study described earlier.
The Social Security Administration has also sought to in-
centivize employment services through its Ticket to Work
program.
128
The President’s New Freedom Commission
was an inspirational product of the executive branch of
the federal government, even if the executive branch
also required that the Commission’s recommendations
be revenue neutral. Revenue neutrality, especially in the
short term, may be incompatible with implementing
evidence-based practices unless a comparable amount of
ineffective services can be discontinued.
Summary and Conclusions
Implementation research in schizophrenia care has
followed the pattern observed in general health care
18
:
moving gradually from passive diffusion to system reen-
gineering based on complex electronic records, decision
supports, and Wagner’s
26
chronic care model. Simple
implementation efforts are often fruitless and waste
resources, while traditional continuous quality improve-
ment approaches are costly and often only moderately suc-
cessful. Complex reengineering of systems is needed.
However, public mental health systems are currently
mired in financing constraints (eg, Medicaid regulations
are not aligned with evidence-based practices), economic
survival problems (state budget problems have eroded
public mental health funding), workforce problems (aver-
age tenure in some front-line positions is less than 18 mo),
regulatory problems (fears of Medicaid audits prevent sys-
tems from innovating), and information technology prob-
lems (currently many states have no electronic medical
records while others have electronic medical records
that emphasize billing and regulatory requirements rather
than quality of services and clinical outcomes). Public
mental health systems need better alignment between ev-
idence-based practices and payments, sufficient funding to
create a sustainable andprofessional workforce, electronic
medical records to monitor process and outcomes, and
a systemic commitment to quality. The research commu-
nity needsmuch greater attentionto the implementationof
effective services in order to improve the care of schizo-
phrenia in the United States.
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Evidence-Based Practices for Schizophrenia Patients
    • "The two year treatment group demonstrated the highest medical costs with €64,509, followed by the one year group with €53,586. The high level of continuous care and the substantial differences in hospital admissions in the continuous care group and the other groups in our study compares very favorably to the reported quality health care in the United States [30,33]. These differences in quality of health care may explain why the reduction of hospital admissions by assertive community treatment in the United States could not be replicated in the United Kingdom or the Netherlands [38,39]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment. Methods: Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008-2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs. Results: Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509. Conclusions: Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.
    Full-text · Article · Jun 2016
    • "The importance of psychosocial interventions aimed at providing such support is sustained by studies showing that pharmacological treatment alone may not suffice for illness management (Buchanan et al., 2010; Kane, 1995). However, lack of trained staff or limited funding limit the availability of these interventions (Drake et al., 2009 ). This notion provides a call for programs to introduce additional resources of social and emotional support for people with schizophrenia-spectrum disorders , which are both cost effective and easy to implement in realworld conditions. "
    [Show abstract] [Hide abstract] ABSTRACT: The aim of this study was to describe the adaptation of a program designed to leverage 7 Cups of Tea (7Cups), an available online platform that provides volunteer (i.e., listener) based emotional support, to complement ongoing treatment for people with schizophrenia-spectrum disorders. The adaptation of the program was based on two stages: First, following platform demonstration, six clinicians specializing in the treatment of schizophrenia completed a survey examining attitudes towards the program and suggested modifications. In response to clinicians' feedback, a computerized training program that provides information for listeners supporting people with schizophrenia was developed, and one hundred and sixty eight listeners completed an online knowledge test. In the second stage, 10 outpatients with schizophrenia-spectrum disorders were recruited to chat with listeners, provided post-session open-ended comments as well as usability and usefulness ratings assessed on a five point Likert scale. The additional training significantly increased listeners' knowledge and confidence (0.38<=Cohen's d<=1.14, p<=.024). Patients' attitudes toward the listeners were positive and they expected the platform will be usable and helpful. Most patients expected a positive gain by having the opportunity to receive an outlet for emotions and socialize. The authors conclude that the use of an available digital platform resulted in a feasible intervention in terms of cost and availability, which is now ready for evaluation in real-world settings.
    Full-text · Article · Mar 2016
    • "Both cognitive behavior therapy (CBT) and structured family interventions (FI) are recommended psychological treatments for psychosis in clinical guidelines around the world (Gaebel et al. 2005). However, equally widespread is evidence of poor levels of implementation of both CBT and FI (Drake et al. 2009; Kuipers 2011; Mojtabai et al. 2009; Resnick et al. 2005) and recognition of the urgent need to find ways to increase availability (The Schizophrenia Commission 2012; Dausch et al. 2012; Farhall and Thomas 2013). Of these two recommended interventions, there is some evidence that individual CBT has been the more successfully implemented, particularly in the UK National Health Service (NHS) (Haddock et al. 2014). "
    [Show abstract] [Hide abstract] ABSTRACT: Working with families in psychosis improves outcomes and is cost effective. However, implementation is poor, partly due to lack of a clear theoretical framework. This paper presents an interpersonal framework for extending the more familiar cognitive behavioral therapy model of psychosis to include the role of relatives’ behavior in the process of recovery. A summary of the framework is presented, and the evidence to support each link is reviewed in detail. Limitations of the framework are discussed and further research opportunities highlighted. Clinical implications and a case example are described to show how the framework can be used flexibly to facilitate clinical practice. Our aim is to shift the focus of psychosocial interventions from an individualistic approach to treatment, towards greater involvement of relatives and recognition of the importance of the social environment on mental health. Electronic supplementary material The online version of this article (doi:10.1007/s10608-015-9731-3) contains supplementary material, which is available to authorized users.
    Full-text · Article · Dec 2015
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